Every finding on record at Hilltop Skilled NSG & Rehab

Based on observation, interview, and record review the facility failed to provide timely antibiotic treatment and provide perineal care after toileting for one resident (R3) out three residents reviewed for infection control in a sample list of four residents. Findings include:R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively impaired and requires maximum assistance with toileting.R3's Nurse Progress Note dated 3/18/2026 at 6:06 PM documents R3 will return to the facility with a diagnosis of urinary tract infection (UTI) and will be on an antibiotic.R3's Nurse Progress Note dated 3/18/2026 at 6:55 PM documents R3 returned from the hospital with UTI and orders for Cephalexin (antibiotic) 500 milligrams (mg), one capsule every eight hours for ten days. R3's Hospital discharge instructions dated 3/18/2026 documents a physician order for Cephalexin 500 mg oral capsule, give by mouth every 8 hours.R3's Medication Administration Record (MAR) for March 2026 documents Cephalexin was initiated on 3/24/2026 at 9:00 AM.R3's urine culture and sensitivity (C&S) dated 3/20/2026 is documented as complete at 8:40 AM.On 4/8/2026 at 1:20 PM, V11 and V12 (Certified Nurses Assistants) assisted R3 to the toilet. After R3 finished using the toilet V11 and V12 did not cleanse R3's front perineal area.On 4/7/2026 at 11:00 AM, V4 Assistant Director Nursing (ADON)/ Infection Preventionist (IP) stated the facility has a backup medication dispenser for newly ordered medications. V4 stated the facility has an after hours and emergency pharmacy if medication needed is not available in the backup dispenser. V4 stated the expectation is for staff to provide immediate antibiotic treatment for infections. V4 stated R3's antibiotic was held until the urine culture and sensitivity (C&S) was resulted. V4 stated the facility is not able to receive laboratory results on the weekends. V4 stated facility staff called the hospital on 3/18/26 and left a message asking for R3's C&S results. V4 stated they have difficulty reaching the hospital medical records for laboratory results. V4 stated they called the hospital on 3/18/2026 and left a message asking for the C&S results. V4 stated that they were unaware the results were completed. On 4/7/2026 at 12:50 PM, V10 (Release of Information Representative at the hospital) responded on the first attempt to call the medical records department. V10 stated that when a facility calls for laboratory results they are sent immediately via facsimile. V10 stated the turn around time for laboratory results is immediate and they are processed within the day of request.

Based on observation, interview and record review the facility failed to provide palatable foods for residents. This failure has the potential to affect all 64 residents residing in the facility. Findings include:The facility daily midnight census dated 2/6/26 documents 64 residents reside in the facility.The facility Food Committee Meeting Minutes dated 12/8/25 documents the broccoli soup tasted scorched and was not mixed well and the tomato soup was watered down. The facility Food Committee Meeting Minutes dated 1/23/26 documents residents are not happy with evening meals and the night meal is not good. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact.R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact.On 2/6/26 at 12:25 PM, R1 stated the food looked good and tasted good. R1 stated It's a welcome surprise because the food is usually awful. R1 stated the food is served cold and inedible. R1 stated there are times you cannot decipher what the food is.On 2/6/26 at 12:35 PM, V9 Manager in Training served a test tray of food. V9 obtained the temperatures of the sample portion of chicken which was 163 degrees, macaroni and cheese was 180 degrees and mixed vegetables ranged from 110-125 degrees. V9 used her bare hands to push the mixed vegetables together in order to increase their temperature. V9 stated the vegetables were not at the right temperature and felt 'cold'.On 2/6/26 at 3:10 PM R2 stated the food is 'atrocious'. R2 stated the french fries are soggy, and the food is burned with black crust all over it. R2 stated the chicken is dry and leathery, the bread is left out, so it gets dry, the pasta is either mushy or crunchy and the meals are cold. R2 stated the meals are not appealing. R2 stated the facility does have an alternative menu but the foods are still burned or mushy. R2 stated she has asked for chocolate milk and was told chocolate milk is a 'luxury' and the facility can't be expected to fill such an 'extravagant and expensive' request. On 2/10/26 at 8:50 AM, R3 stated the facility has had a 'major' problem with the kitchen not serving hot, appetizing, and tasty meals. R3 stated the foods served have been cold, not appealing to look at, and not cooked properly. R3 stated Here let me show you pictures. R3 showed pictures of what she called garlic toast where one side was white bread, and the other side was entirely dark black with a thick swipe of yellow paste (butter) all over it. R3 stated she asked about this and was told that there were two pieces of sliced bread that the dietary staff put into the same toaster slot, so one side was burned and one side was white. R3 showed another picture of a ground ball of red unidentified food. This unidentified food had the shape of a kitchen serving scoop. R3 stated this was lasagna. There were no signs of cheese, noodles, meat, spice, etcetera. R3 stated once she cut into the red ball, there was one piece of a lasagna noodle. R3 stated two days ago (2/8/26) the facility served what was supposed to be chicken pot pie, but it did not have any crust. R3 showed a picture of the chicken pot pie which showed mixed vegetables in gravy in a flat layer on a plate with no bread/crust included. On 2/6/26 at 10:30 AM, V8 Certified Dietary Manager (CDM) stated she has been onsite since Wednesday 2/4/26. V8 stated prior to her being onsite a dietary district manager CDM (V7) was onsite to assist with the kitchen concerns. V8 CDM stated the facility kitchen has had a multitude of problems with staffing turnover and multiple resident complaints of food that is overcooked, not appealing to look at and/or cold.

Based on observation, interview and record review the facility failed to prevent cross contamination during meal services. This failure has the potential to affect all 64 residents residing in the facility. Findings include:The facility daily midnight census dated 2/6/26 documents 64 residents reside in the facility.The facility meal menu dated 2/6/26 documents the lunch meal will consist of fried chicken, mashed potatoes with gravy, creamed corn, drink and banana pudding. On 2/6/26 at 11:58 AM, V9 Manager in Training stated the fried chicken was not at a high enough internal temperature to serve. V9 was assisting in preparing other foods to be served. V9 then walked over to the service line, wiped her bare hands on her pants and picked up a thermometer by the shaft with her palm and fingers making full contact. V9 used this contaminated thermometer to test six pieces of chicken in a full pan of fried chicken. V9 then stated none of the chicken pieces tested were at the appropriate temperature so she used potholders that were laying on the contaminated counter to place that pan of chicken back in the oven. V9 then using the same potholders removed a second pan of chicken out of the oven. V9 again picked up the thermometer with her palm and fingers. V9 used the same contaminated thermometer to test the temperature of eight pieces of chicken from the second pan. V9 repeated this process with the first and second pans two more times until the internal temperature was safe to serve to the residents. On 2/10/26 at 9:00 AM, V8 Certified Dietary Manager (CDM) stated V9 should have washed her hands and wiped off the thermometer prior to obtaining the temperature of the chicken. V8 stated there is a lot of education to be done and V8 will continue to educate staff.

Based on observation, interview and record review the facility failed to ensure the safety of four (R1, R2, R4, R5) residents through the use of extension cords for medical devices out of four residents reviewed for physical environment in a sample list of five residents. Findings include:1.R1's Electronic Medical Record (EMR) documents medical diagnoses as Obstructive Sleep Apnea, Chronic Respiratory Failure, Heart Failure and Atrial Fibrillation.R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact.On 2/6/26 at 3:33 PM, R1's Nebulizer machine, Oxygen concentrator and BI-PAP machine were all plugged into an outlet strip extension cord which was plugged into the wall outlet. R1 stated she only has one outlet, so her bed and the extension cord is plugged into her outlet. 2.R2's Electronic Medical Record (EMR) documents medical diagnoses as Asthma, Morbid Obesity, Atrial Fibrillation, Pericardial Effusion, Obstructive Sleep Apnea, Heart Failure, Cardiomyopathy, Chronic Respiratory Failure and Hypoxia.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact.On 2/6/26 at 3:15 PM, R2's pacemaker monitor, and Nebulizer machine were plugged into an outlet strip extension cord that was attached to the wall beside her window. R2 pointed to her extension cord and stated, 'that looks like a fire hazard to me, but what do I know'. 3.R4's Electronic Medical Record (EMR) documents medical diagnoses as Chronic Respiratory Failure, Obstructive Sleep Apnea, Tachycardia and Chronic Obstructive Pulmonary Disease (COPD)R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 2/10/26 at 3:15 PM, R4's BI-PAP and Nebulizer machine was plugged into an outlet strip extension cord which was plugged into the wall outlet. R4's Oxygen concentrator was plugged into a separate outlet strip extension cord behind her recliner chair. 4.R5's Electronic Medical Record (EMR) documents medical diagnoses as Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease (COPD), Malignant Neoplasm of Bronchus and Lung, Pulmonary Fibrosis, Emphysema and Chronic Pulmonary Edema.R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact. On 2/10/26 at 10:00 AM, R5's Oxygen concentrator was plugged into an outlet strip extension cord. R5 stated she sometimes puts her Nasal Cannula on or takes it off 'but I never mess with the plug ins'. On 2/10/26 at 2:45 PM, V5 Maintenance Director stated the room outlets are going to be changed to hospital grade circuit breaker types over a period of time. V5 stated once the outlets are changed out residents will have more outlets to plug medical devices into. V5 stated there is really no other way around this situation other than to change out all of the electrical outlets across the facility. V5 stated plugging in multiple medical devices that require more of an electrical draw into an outlet strip that is plugged into the wall outlet could be a fire hazard. On 2/10/26 at 3:00 PM, V1 Administrator stated the facility is in the process of changing all the electrical outlets as a concern arises. V1 Administrator stated there are multiple residents who have multiple medical devices that are plugged into an extension cord due to that is the only option. V1 Administrator stated the facility does not have a policy for the use of medical devices plugged into an extension cord.

Based on observation, interview, and record review the facility failed to accurately transcribe and administer diabetic wound care as ordered for one of six residents (R13) reviewed for wounds in the sample list of 28. Findings include:On 12/15/2025 at 12:39 PM R13 stated prior to admission R13 stepped on a rusty nail and got a nasty infection resulting in amputation of his toes/portion of his left foot. R13 stated the nurses don't always follow the wound physician orders that R13 brings back from the wound clinic. R13's was wearing an orthotic boot on his left foot, and his foot was wrapped with a dressing. R13 was missing the lower half of his foot. R13's Minimum Data Set (MDS) dated dated 11/11/25 documents R13 as cognitively intact. R13's Care Plan dated 11/20/25 documents R13 has left plantar diabetic wound and osteomyelitis (infection/inflammation of the bone). Interventions include to administer treatments per physician's orders. R13's Wound Center Progress Notes dated 11/19/25 and 12/10/25 recorded by V14 Wound Physician, document the following: Apply (wound cleanser) to gauze and soak left plantar foot wound for five minutes for suspected biofilm; and apply (antimicrobial foam dressing) soaked in normal saline or sterile water with excess squeezed out, cover with abdominal pad, wrap with gauze roll, and secure with tape twice per week. On 12/10/25 this treatment was increased to daily and R13's wound measured 0.9 centimeters (cm) long x 1.4 cm wide x 0.9 cm deep with undermining. R13's December 2025 Treatment Administration Record (TAR) documents treatment administration 11/10/25-12/10/25 to cleanse wound with (wound cleanser), soak (antimicrobial foam dressing) in (wound cleanser) and apply to wound bed twice weekly; this same order was increased to daily on 12/10/25. These orders do not match V14's orders noted above. On 12/17/25 at 10:20 AM V13 Wound Nurse and V20 MDS/Care Plan Coordinator entered R13's room and administered R13's wound care. R13 did not have any toes to his left foot and a portion of his foot had been amputated. R13's wound was deep and wound bed was pink with white edges. V13 measured R13's wound which was 2 cm x 1.7 cm x 0.6 cm, and had no undermining or tunneling. V13 used gauze soaked in (wound cleanser) to cleanse/wipe R13's wound and did not soak the wound for five minutes. V13 administered R13's wound treatment as indicated on R13's TAR, and not per V14's orders to soak (antimicrobial foam dressing) in normal saline or sterile water. V20 placed the scissors used to cut the clean (antimicrobial foam dressing) into her pocket. On 12/17/25 at 11:00 AM V13 confirmed R13's current wound treatment order does not match the order on R13's 12/10/25 Progress Note, it does not include to soak the wound for five minutes or to soak the (antimicrobial foam dressing) in normal saline or sterile water. V13 stated 12/10/25 was R13's most recent wound provider visit. 12/17/25 at 11:06 AM V14 Wound Physician stated staff should allow R13's wound to soak with (wound cleanser) for five minutes to help with biofilm removal, which would be better than just typical cleansing. V14 stated staff should not be soaking the (antimicrobial foam dressing) in (wound cleanser), it should be soaked in normal saline or sterile water which is what activates the (antimicrobial foam dressing.) V14 stated soaking the (antimicrobial foam dressing) in the (wound cleanser) could alter the affects. The manufacturer's instructions for use for (antimicrobial foam dressing) dated 2024 documents to moisten the dressing with normal saline or sterile water prior to applying to the wound bed. The facility's Non-pressure skin impairment policy dated 3/3/23 documents to review and update the resident's current orders.

Based on interview and record review the facility failed to accurately complete a minimum data set (MDS) assessment for one of 24 residents (R31) reviewed for MDS in the sample of 28. Findings include: On 12/16/2025 at 9:44 AM R31 stated R31 receives dialysis three times per week. R31's MDS dated [DATE] does not include dialysis. R31's August and September 2025 nursing notes document R31 receives dialysis. On 12/16/2025 at 11:16 AM V20 MDS/Care Plan Coordinator reviewed R31's 9/26/25 MDS and stated R31 is still on dialysis and that should have been reflected on R31's MDS. V20 stated V20 will need to submit a correction.

Based on observation, interview, and record review the facility failed to perform hand hygiene prior to applying personal protective equipment and prior to wound care, disinfect scissors during wound care, and failed to ensure a urinary catheter was kept off the floor for two of 24 residents (R13, R49) reviewed for infection control in the sample list of 28. Findings include: 1.) On 12/15/2025 at 11:17 AM R49 was lying in bed asleep. R49's bed was low to the floor and R49's urinary catheter drainage bag and tubing was lying on the floor. On 12/15/25 at 2:30 PM R49's bed was low to the floor and R49's urinary catheter bag/tubing was on the floor. At 2:37 PM V8 Licensed Practical Nurse entered R49's room and confirmed R49's catheter bag/tubing was on the floor. V8 confirmed catheter bag and tubing should be kept off the floor. The facility's Indwelling Catheter Care policy dated 10/7/22 documents Be sure the catheter tubing and drainage bag are kept off the floor. 2.) On 12/15/2025 at 12:39 PM R13 stated prior to admission R13 stepped on a rusty nail and got a nasty infection resulting in amputation of his toes/portion of his left foot. R13's was wearing an orthotic boot on his left foot, and his foot was wrapped with a dressing. R13 was missing the lower half of his foot. R13's Care Plan dated 11/20/25 documents R13 has left plantar diabetic wound and osteomyelitis (infection/inflammation of the bone). On 12/17/25 at 10:20 AM V13 Wound Nurse pushed the treatment cart down the hallway to outside of R13's room. V20 MDS/Care Plan Coordinator joined V13 outside of R13's room. Both applied gown and then gloves, but did not perform hand hygiene prior and entered R13's room. R13's room door had a sign posted indicating Contact Isolation. V13 removed the elastic bandage covering R13's left foot. V20 removed scissors from her pocket R13's dressing that had tan drainage on the bottom of R13's foot. V20 placed the scissors back into her pocket and had not disinfected the scissors before/after cutting off R13's dressing. R13 did not have any toes to his left foot and a portion of his foot had been amputated. R13's wound was deep and wound bed was pink with white edges. V13 measured R13's wound which was 2 cm x 1.7 cm x 0.6 cm, and had no undermining or tunneling. V13 administered R13's wound treatment. V20 placed the scissors used to cut the clean (antimicrobial foam dressing) into her pocket. At 10:45 AM V13 and V20 confirmed they had not completed hand hygiene prior to applying gown/gloves before entering R13's room. V13 stated bleach wipes are used to disinfect scissors prior to and after use. V13 and V20 both confirmed they had not disinfected their scissors used during R13's wound treatment prior to placing the scissors into their pockets. V13 stated R13 is on contact isolation due to a wound infection which was done as a precaution and R13's wound culture results are pending.On 12/17/25 at 11:25 AM V16 Assistant Director of Nursing/Infection Preventionist stated staff should perform hand hygiene before/after and during wound care. V16 confirmed staff should perform hand hygiene prior to applying personal protective equipment. V16 stated a bleach wipe should be used to disinfect scissors after use. V16 stated R13 did have Methicillin Resistant Staphylococcus Aureus in a prior wound culture, but we are waiting for culture results for current wound culture. The facility's undated Handwashing/Hand Hygiene policy documents hand hygiene is considered the primary means to prevent the spread of infections to personnel, residents and visitors. Use an alcohol based hand rub or alternatively soap and water before/after entering isolation precaution settings and before direct contact with residents. The facility's Isolation Equipment and Supplies policy dated 3/28/22 documents the nursing department will notify environmental services when equipment used to care for a resident needs to be sanitized.

Based on interview and record review the facility failed to properly implement fall interventions for one of three (R1) residents reviewed for falls on the sample list of four. This failure resulted in R1 falling and sustaining a left femoral neck fracture. This past noncompliance occurred from 5/1/25 through 5/9/25. Findings Include: The Full QA Report dated 5/1/25 documents R1 had a witnessed fall on 5/1/25 at 12:05 AM. R1 attempted to stand up from her wheelchair and fell to the ground. R1's chair alarm did not sound. R1 displays poor dynamic sitting/standing balance as well as impulsiveness related to her advanced Dementia diagnosis. V4 Certified Nurses Assistant (CNA) was walking by the hallway and observed R1 attempt to stand then lose her balance and fall to the ground. V4 notified the nurse on duty (V3 Registered Nurse RN). R1's emergency room documentation dated 5/6/25 documents R1 had a fall on 5/1/25 onto her left hip. R1 complained of pain and an X-ray was completed on 5/2/25. The x-ray showed possible deformity to the left hip and a recommendation for further testing was indicated. On 5/6/25 R1 was sent to the emergency room to get a computed tomography (CT) scan completed of her left hip. R1's Radiology Report dated 5/6/25 documents R1 sustained a mildly impacted non-displaced left femoral neck fracture status post fall and suspicious findings on x-ray imaging. R1's Medical Diagnoses list dated May 2025 documents R1 is diagnosed with Vascular Dementia, Cognitive Communication Deficit, Impulse Disorder, Insomnia, Personal History of a Traumatic Brain Injury. R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired, requires substantial assistance from staff to safely transfer from a seated position, and requires the use of a manual wheelchair for mobility. R1's Fall Risk assessment dated [DATE] documents R1 is at high risk for falls due to her disorientation, 1-2 falls in the past three months, chair bound and requiring assistance with elimination and takes medications that put her at risk. R1's Care Plan dated 3/18/25 documents R1 is at high risk for falls related to impaired safety awareness, poor memory, inability to retain information, attempts to self-transfer, and inability to retain safety reminders from staff. R1 has multiple fall interventions in place which include low bed with fall mats, a scoop mattress, anti-rollbacks on her wheelchair, and a pull tab alarm when in her wheelchair. R1's Care Plan documents R1 has a pull tab alarm on her wheelchair, in place for safety related to falls and a lack of safety awareness. R1's alarm is to be maintained and functioning when it is in place on her wheelchair. Staff are to check placement and functioning of R1's alarm every shift and as needed. R1 also has no safety awareness related to a cognitive deficit. Staff are to monitor R1's whereabouts regularly. On 5/20/25 at 2:43 PM V3 Registered Nurse stated she was the nurse on duty when R1 fell on 5/1/25. V3 confirmed she was alerted of R1's fall by V4 CNA and observed R1 on the floor. V3 stated R1's tab alarm was still attached to her shirt and to the magnetic tab and was not sounding. V3 stated she pulled the alarm off the magnet, and the alarm sounded. V3 confirmed the alarm string must have been too long. On 5/20/25 at 11:30 AM V2 Director of Nurses confirmed R1 fell to the floor on 5/1/25 when she attempted to stand unassisted from her wheelchair. V2 confirmed the fall was witnessed by V4 CNA. V2 confirmed even though R1's pull-tab alarm was on and functioning, it did not sound as R1 stood up from her chair. V2 stated staff should have made sure the string on the pull-tab alarm was at the proper length and it was not attached to baggy clothing which could cause it to not work properly or pull from the magnet when R1 was beginning to lean forward to stand. V2 confirmed R1 sustained a left femoral neck fracture from the fall on 5/1/25. Prior to the survey date of 5/16/25, the facility had taken the following actions to correct the noncompliance: 1. In-services were completed to educate the nursing and CNA staff about the importance of properly implementing all fall interventions and regarding the accidents policy. 2. The accidents/fall policy was reviewed and updated. 3. Residents were identified who could be affected by the failure and resident care plans and fall interventions were reviewed. 4. Audits were completed to ensure the staff were following the fall policy and implementing fall interventions. 5. Audit results were discussed at the facility's Quality Assurance Program Improvement meetings.

Based on interview and record review the facility failed to protect the right of a resident to be free from misappropriation of their medication. This failure had the potential to affect one of three residents (R2) reviewed for misappropriation on the sample list of five. This past noncompliance occurred from 4/16/25 through 4/24/25. Findings Include: The facility's Abuse Policy dated 9/15/23 documents the facility affirms the right of residents to be free from misappropriation of property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent. The facility's Controlled Substances policy dated 5/11/20 documents, controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Upon receipt, the nurse receiving the medication and the individual delivering the medication verify the name, dose, and quantity of each controlled substance being delivered. The Full QA Report dated 4/16/25 documents at approximately 3:05 PM the facility received an allegation of misappropriation of controlled medications. V5 Licensed Practical Nurse (LPN) reported the pharmacy denied R2's refill of Tramadol stating it was too early because 120 tablets were just delivered on 3/25/25. Upon investigation, it was noted that 60 tabs of Tramadol were unaccounted for. The medications and corresponding count sheets were missing. R2's Medical Diagnoses list dated May 2025 documents R2 is diagnosed with Depression, Anxiety, Osteomyelitis, and History of Breast Cancer. R2's Physician Order Sheet dated May 2025 documents an order for Tramadol 50 milligrams, one tablet by mouth four times per day. R2's Medication Administration Record dated March through May 2025 documents all doses of Tramadol were given per physician order. R2's Pharmacy Delivery Record dated 3/25/25 documents on 3/25/25 the pharmacy delivered 120 tablets of Tramadol 50 milligrams to the facility for R2. R2's Tramadol Narcotic Count Sheets were reviewed from February 2025 through current. There were no Tramadol narcotic count sheets for 3/20/25 through 3/31/25. Two count sheets, each for 30 tablets of Tramadol were missing. On 5/20/25 at 1:49 PM V8 Licensed Practical Nurse LPN stated she was the receiving nurse from the pharmacy for R2's Tramadol on 3/25/25. V8 stated she is not sure how many tablets were in the bag because at that time she never actually verified the number of controlled substances being delivered. She just signed the receiving paperwork and delivered the medications to the appropriate hall nurse. On 5/20/25 at 11:30 AM V2 Director of Nurses verified on 4/16/25 V5 LPN reported to him that there seemed to be some Tramadol missing from R2's medications. V2 DON confirmed on 3/25/25 the pharmacy delivered 120 tablets of Tramadol 50 milligrams for R2. V2 confirmed the receiving nurse that day was V8 LPN who did not verify the number of Tramadol tablets she was receiving from the pharmacy. V2 confirmed he is not sure what happened to the 60 tablets of Tramadol and there are also two missing count sheets for R2's Tramadol. V2 stated he is not sure if someone took them. V2 stated it is hard to prove because the reconciliation process was not done correctly when the medications were received. Prior to the survey date of 5/16/25, the facility had taken the following actions to correct the noncompliance: 1. In-services were completed to educate the nursing staff about the new process for receiving medications from the pharmacy and regarding the controlled medication policy. 2. The controlled medication policy was reviewed and updated. 3. Residents were identified who could be affected by the failure and resident medication count sheets and medication administration records were reviewed. 4. Audits were completed to ensure the staff were following the new process for receiving medications from the pharmacy and to ensure staff were following the controlled medication policy and procedures. 5. Audit results were discussed at the facility's Quality Assurance Program Improvement meetings.

Based on observation, interview and record review the facility failed to provide foods that were palatable and at appropriate temperatures, and failed to provide a meal for a resident for five of nine residents (R8, R20, R30, R53, R163) reviewed for dining in a sample list of 43 residents. Findings include: The facility Resident Council Minutes for the Month of July, 2024 document resident concerns of the food being served cold. The facility Resident Council Minutes for the Month of August, 2024 document resident concerns of the ''food temperatures not being warm enough and food sometimes comes out burned. The facility Resident Council Minutes for the Month of September, 2024 document resident concerns that the facility needs to update diet tickets two times a year with likes and dislikes. The facility Resident Council Feedback form dated 9/20/2024 documents Department Response: Tickets will be updated with likes and dislikes twice yearly. 1.) R163's undated Face Sheet documents medical diagnoses as Heart Failure, Pulmonary Edema, End Stage Renal Disease, Chronic Respiratory Failure, Toxic Encephalopathy and Weakness. R163's Admission assessment dated [DATE] documents R163 as cognitively intact. R163's Physician Order Sheet (POS) dated October 2024 documents a physician diet order of Regular diet, Regular texture, Thin/Regular consistency with Renal precautions. R163's Care Plan goal dated 10/15/2024 documents R163 receives Hemodialysis due to end stage renal failure. On 10/15/24 at 12:55 PM the cart carrying the meal trays for 300 hall where R163 resides was delivered to 300 hall. This same cart was not plugged in and was not warm. On 10/15/24 at 1:10 PM R163 was served his lunch meal in his room. R163's lunch plate was delivered without the cover. On 10/15/24 at 1:20 PM V9 Dietary Manager obtained temperatures of R163's lunch meal items. R163's macaroni salad had a temperature of 45.2 degrees Fahrenheit (F), Spinach 105.5, pork chop with pork gravy 78.6. F. On 10/15/24 at 1:15 PM R163 stated I haven't had a warm meal yet. Every single meal is served cold. They (staff) try to warn it up but by the time my food comes back to me it's cold again. I have to order out (pointing at fast food bag on dresser). I am only here to get therapy and then can go home again. Yesterday I had (Renal) Dialysis at 11:30 AM. I was in the chair for four and a half hours and then the drive back here to the facility. I didn't get back until about 5:00 PM. They (facility) didn't give me anything to eat or send any food with me. I was completely worn out by the time I got back. Why can't they (facility) just serve the meals warm and not forget to feed people their meals? On 10/15/24 at 1:25 PM V9 stated R163 is on a renal diet. V9 stated R163's lunch meal items of spinach and pork chop with gravy were not at a safe temperature. V9 stated R163's food temperatures should have been hotter. V9 stated R163's macaroni salad temperature was too warm. V9 stated the facility does not have warmer plates or carts to serve the resident's food on. V9 stated I know this has been a problem and I have asked for more equipment to be able to serve the resident's warm meals but I only have what I have. We (facility) do the best with what we have. Unfortunately we (facility) just do not have the equipment we need. V9 Dietary Manager stated (R163) did not receive a lunch meal on 10/14/24 and should have. (R163) was served a grilled cheese sandwich when he returned but that was at the same time as supper so in reality he really did miss an entire meal. 2) R53's undated Face Sheet documents medical diagnoses as Severe Protein-Calorie Malnutrition, Nonalcoholic Steatohepatitis, Cirrhosis of Liver, Ischemic Cardiomyopathy, Myocardial Infarction and Chronic Kidney Disease. R53's Physician Order Sheet (POS) dated October 2024 documents a physician diet order of NAS (No Added Salt) diet, Regular texture, Thin/Regular consistency, Heart Healthy for 2000 milligram (mg) sodium restriction, low fat, low cholesterol diet. R53's Minimum Data Set (MDS) dated [DATE] documents R53 as cognitively intact. On 10/15/24 at 1:00 PM R53 was served a polish sausage, spinach, macaroni salad and a full piece of chocolate chip cake. R53 ate 25% of her meal. On 10/15/24 at 11:40 AM R53 stated The riblets they (facility) served for supper last night (10/14/24) were hard as a brick. I couldn't eat them. I like ribs too. I would have enjoyed even having the fake ribs. It was a real disappointment. Lots of times they (facility) run out of the main meal so they serve us whatever they have in the store room. One time, I was supposed to get the ham and potatoes and they gave me a cold bologna sandwich instead. I am supposed to watch what I eat because of my heart. I am pretty sure bologna is not heart healthy. 3.) R8's undated Face Sheet documents medical diagnoses as Comminuted Fibula Fracture, Morbid Obesity, Diabetes Mellitus Type II, Chronic Respiratory Failure, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominate side, Obstructive Sleep Apnea, Pulmonary Hypertension, Legal Blindness and Dependence on Supplemental Oxygen. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. On 10/16/24 at 1:00 PM R8 was sitting at her dining room table. R8 had eaten less than 10% of her meal. On 10/16/24 at 1:15 PM R8 was sitting at the dining room table. R8 had eaten less than 10 % of her meal. On 10/15/24 at 1:40 PM R8 stated The food is inedible. The ribs they (facility) served last night (10/14/24) were so tough you couldn't even stab a fork in them. They were awful. Many of the meals are so over cooked you can't eat them. The food is cold and awful. On 10/16/24 at 1:18 PM R8 stated Today's lunch was polish sausage, spinach and macaroni salad. The sausage was greasy and cold, the spinach was cold and the macaroni salad didn't have any flavor. I told them (staff) about it and they brought me a pudding cup. That is not a meal. They (facility) really need to work on their food. 4.) R30's undated Face Sheet documents medical diagnoses as Nondisplaced Fracture of Right Femur, Diabetes Mellitus Type II, Morbid Obesity, Myelodysplastic Syndrome, Chronic Pulmonary Edema, Cardiomyopathy, Pulmonary Hypertension, Benign Paroxysmal Vertigo, Vitamin D Deficiency and Carpal Tunnel Syndrome. R30's Minimum Data Set (MDS) dated [DATE] documents R30 as cognitively intact. R30's Physician Order Sheet (POS) dated October 2024 documents a physician ordered diet of Consistent Carbohydrate diet, Regular texture, Thin/Regular consistency On 10/15/24 at 10:10 AM R30 stated I go to the meeting for residents and complain there too because I am sure I am not the only one who can't eat the food. But what if someone doesn't like the food and just can't speak up for themselves. I feel like I should do that. I have to order out because the food is like dog food. It is never hot. The riblets last night were horrible. I couldn't even cut through them they were so overcooked. They were harder than jerky. 35347 5. On 10/1520/24 at 2:04PM, R20 reported eating all meals in R20's room and reported the facility meals are always cold. On 10/17/2024 at 12:01PM, dietary staff were assembling resident meals in the facility kitchen on ceramic plates. The plates were stored at room temperature beside the service line and were not held inside of any warming device. On 10/17/2024 at 12:30PM, a transportation/warming cart containing resident meal trays was located in the 100 hallway. The cart was not plugged into an electrical receptacle and the interior of the cart was room temperature.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to include residents with denture problems. This failure affects two residents (R16 and R41) out of three reviewed for dental problems on the sample list of 43. Findings include: 1. On 10/15/24 at 10:51 AM, R16's upper denture was falling down to her lower lip while speaking. R16 was pushing the denture upwards with her tongue and lower lip repeatedly during a brief conversation, impairing R16's speech pattern. R16's Census Detail dated 10/18/24 documents R16 was admitted to the facility 9/10/24. R16's Comprehensive Minimum Data Set (MDS) dated [DATE] Section L documents R16 has no broken or loosely fitting dentures. R16's Care Plan dated beginning 9/11/24 does not include any focus or problem area about R16's dentures including proper fit or cleaning care. 2. On 10/16/24 at 09:57 AM, R41's upper denture was falling down to her lower lip while speaking. R41 was repeatedly pushing the upper denture back into place with her tongue and lower lip during a brief conversation. R41 stated, I don't know if they have any adhesive, I never asked but I know my dentures move around a bit. If I decide to try some adhesive it would be nice to know they have it. R41's Census Detail dated 10/18/24 documents R41 was admitted to the facility 5/6/24. R41's Comprehensive MDS dated [DATE] documents R41 has no broken or loosely fitting dentures. R41's Care Plan dated beginning 5/6/24 does not include any focus or problem area about R41's dentures including proper fit or cleaning care On 10/17/24 at 11:26 AM, V12, Minimum Data Set Coordinator (MDSC), stated, Those MDS were completed by (V13, former MDSC), who worked like a consultant and was not here at the facility but was completing the MDS offsite, so the 'unable to examine' was because (V13) was not onsite to do an examination of the residents. V12 further stated, I don't know if coding the loosely fitting dentures would trigger a CAA (Care Area Assessment) for a care plan, but I can confirm that the dental CAA is not triggered in Section V. The Minimum Data Set Manual dated October 2024 for Section L documents, For individualized care planning purposes, consideration should be taken for residents to make sure that they are in possession of their dentures or partials and that they are being utilized properly for meals, snacks, medication pass, and social activities. Additionally, the dentures or partials should be properly cared for with regular cleaning and by assuring that they continue to fit properly throughout the resident's stay.

Based on observation, interview, and record review, the facility failed to maintain cleanliness of resident's mattresses. This failure affects one resident (R3) out of 24 reviewed for environmental cleanliness on the sample list of 43. Findings include: R3's Medical Diagnoses List dated 10/18/24 documents R3 experiences medical conditions including Dementia, Acquired Absence of Right Leg Above the Knee, and Acquired Absence of Left Leg Below the Knee. On 10/15/24 at 1:21 PM, there were smeared and mounded clumps of an unidentified white food substance resembling cake at the foot end of R3's mattress. The two clumps were one and one-half inches long by three-quarters of an inch wide. On 10/16/24 at 3:13 PM, the residue of the clumps of white food substance remained on the foot end of the mattress. The mounded clumps were not present, the surface residue was still on the mattress. On 10/16/24 at 3:18 PM, V10, Certified Nursing Assistant (CNA), stated, As far as I know the housekeeping only cleans the mattresses when they need to be sanitized, I don't know if they have a schedule to clean them on resident's shower days. V10 further stated, The CNAs and the nurses have access to the sanitizing bleach wipes to use, what this looks like is the crumbs were probably on the sheets so when they move the sheets it gets down to the bottom of the bed. On 10/16/24 at 3:23 PM, V11, Housekeeping Supervisor, stated, Housekeepers do clean mattresses for their deep cleaning sessions which they do one resident room daily for deep cleaning. V11 then stated, I know the CNAs brushed off the mattress yesterday because that was this resident's shower day and I was in the room cleaning the floor. The CNAs had asked me if they could swipe the crumbs on the floor so I could sweep them, but they obviously didn't wipe the mattress, just swiped the crumbs on the floor.

Based on observation, interview, and record review, the facility failed to accurately encode residents' minimum data set assessments concerning dental conditions. This failure affects two residents (R16 and R41) out of three reviewed for dental conditions on the sample list of 43. Findings include: 1. On 10/15/24 at 10:51 AM, R16's upper denture was falling down to her lower lip while speaking. R16 was pushing the denture upwards with her tongue and lower lip repeatedly during a brief conversation, impairing R16's speech pattern. R16 stated, I know they have adhesive but I don't like to use it. R16's Census Detail dated 10/18/24 documents R16 was admitted to the facility 9/10/24. R16's Comprehensive Minimum Data Set (MDS) dated [DATE] Section L documents R16 has no broken or loosely fitting dentures. This same MDS section documents unable to examine. 2. On 10/16/24 at 09:57 AM, R41's upper denture was falling down to her lower lip while speaking. R41 was repeatedly pushing the upper denture back into place with her tongue and lower lip during a brief conversation. R41 stated, I don't know if they have any adhesive, I never asked but I know my dentures move around a bit. If I decide to try some adhesive it would be nice to know they have it. R41's Census Detail dated 10/18/24 documents R41 was admitted to the facility 5/6/24. R41's Comprehensive MDS dated [DATE] documents R41 has no broken or loosely fitting dentures. This same MDS documents unable to examine. On 10/17/24 at 11:26 AM, V12, Minimum Data Set Coordinator (MDSC), stated, Those MDS were completed by (V13, former MDSC), who worked like a consultant and was not here at the facility but was completing the MDS offsite, so the 'unable to examine' was because (V13) was not onsite to do an examination of the residents. The Minimum Data Set Manual dated October 2024 for Section L documents the person conducting the dental and oral assessment should use a gloved finger and a light source to examine the resident's mouth, lips, gums, palate, and cheek lining. This same manual documents for the person conducting the assessment to inspect a resident's dentures for cracks, chips, and cleanliness, and removal of the dentures is necessary for adequate assessment. This manual documents the code for 'unable to examine' is to be used for uncooperative residents.

Based on interview and record review the facility failed to complete a recapitulation of stay for one (R58) resident out of one resident reviewed for discharge in a sample list of 43 residents. Findings include: R58's undated Face Sheet documents R58 admitted to facility on 8/20/24 and discharged on [DATE]. R58's Minimum Data Set (MDS) dated [DATE] documents R58 as cognitively intact. This same MDS documents R58 as requiring maximum assistance with toileting, bathing, dressing, personal hygiene and transfers. R58's Physician Order Sheet (POS) dated August 2024 documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Repeated Falls, Amnesia, Intervertebral Disc Degeneration, Benign Prostatic Hyperplasia, Obstructive Sleep Apnea, Acute Respiratory Failure with Hypoxia and Diabetes Mellitus Type II. R58's Electronic Medical Record (EMR) does not document a completed recapitulation of stay. R58's Discharge Plan and Instruction Report dated 8/30/24 documents a section titled 'Recapitulation of Stay' which was blank. On 10/17/24 at 1:35 PM V1 Administrator stated the facility is unable to provide documentation of R58's recapitulation of stay. V1 stated R58 had a brief stay in the facility for therapy. V1 Administrator stated the facility does not have a policy on completing a resident's recapitulation of stay.

Based on interview and record review the facility failed to provide safe and adequate assistance with showers to a dependant resident. This failure affected one of one resident (R39) reviewed for Activities of Daily Living on the sample list of 43. Findings Include: R39's Medical Diagnoses List dated October 2024 documents R39 is diagnosed with Lumbar Spondylopathies, Spinal Cord Injury of Lumbar Region, Neuromuscular Dysfunction of Bladder, Depression, Left and Right foot Drop, and Neurogenic Bowel. R39's Minimum Data Set, dated dated dated [DATE] documents R39 is cognitively intact. No documentation was entered for R39's showering needs. R39's Minimum Data Set, dated dated dated [DATE] documents R39 requires partial to moderate assistance with showering and lower body dressing. R39 requires substantial or maximum assistance for putting on or taking off footwear. R39 requires supervision or touching assistance for tub or shower transfers. R39's Care Plan dated 2/29/24 documents R39 has a self-care deficit and requires one person staff assistance for bathing. R39 is also at risk for falls and needs to be observed by staff for unsteady gait and balance. The undated Shower Schedule documents R39's scheduled shower days are Mondays and Thursdays. R39's Shower Sheets from 8/12/24 through 10/17/24 document R39 did not receive eight of the twenty scheduled showers she should have received. The dates of the missing showers are 8/15/24, 8/29/24, 9/5/24, 9/9/24, 9/12/24, 9/26/24, 10/14/24, and 10/17/24. On 10/17/24 at 3:30 PM R39 stated she is supposed to get assistance with showers two times per week on Mondays and Thursdays. R39 stated most of the staff help her without any issues as she cannot reach her legs, feet, back, private areas, and occasionally needs help with washing her hair. R39 stated she is also a fall risk and does not feel safe being in the shower room, in the shower chair alone. R39 stated one particular staff member (V8 Certified Nurses Assistant CNA) does not want to provide the necessary assistance R39 requires for safe showering. V8 will either refuse to assist her with getting washed up or she will leave R39 in the shower room by herself and instruct her to pull the call cord when she is done. R39 stated this makes her feel uncomfortable and unsafe and she is not sure why V8 CNA doesn't want to help her (R39). R39 stated she will refuse showers if V8 is the one that is supposed to give it to her or sometimes V8 CNA won't even offer to give her showers. R39 stated on average she actually gets about one shower per week although she would like to receive the scheduled two showers per week at least. On 10/18/24 at 11:02 AM V2 Director of Nurses confirmed staff are never to leave residents in the shower room in the shower chair alone. V2 confirmed R39 does require some assistance from staff to shower and is a fall risk, especially on wet tile or when attempting to maneuver the shower chair. V2 confirmed residents are scheduled for two showers per week. V2 confirmed V8 CNA should be assisting R39 with showers with a kind and respectful attitude. V2 confirmed R39's medical record should document all of her scheduled showers were either given or refused. The undated Bath or Shower Procedure documents the purpose of the procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Staff is to stay with the resident throughout the bath and never leave the resident unattended in the shower. If feasible, the resident may bathe him or herself and staff will assist as needed. Staff are to assist with drying the resident and clothing the resident. Staff are to document procedure in the resident's electronic health record.

Based on observation, interview and record review the facility failed to ensure resident medical equipment was properly utilized for three (R8, R18, R42) residents out of three residents reviewed for safety in a sample list of 43 residents. Findings include: 1.) R8's undated Face Sheet documents medical diagnoses as Comminuted Fibula Fracture, Morbid Obesity, Diabetes Mellitus Type II, Chronic Respiratory Failure, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominate side, Obstructive Sleep Apnea, Pulmonary Hypertension, Legal Blindness and Dependence on Supplemental Oxygen. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R8's Hospital Discharge Record dated 10/11/24 documents R8 is to utilize 5 Liters of Oxygen per Nasal Cannula continuously. On 10/15/24 at 11:55 AM R8 was wearing her nasal cannula with her oxygen concentrator set at 5 Liters. R8's Oxygen concentrator was plugged into a pink extension cord laying on top of her bedside dresser. On 10/16/24 at 1:15 PM R8 was wearing her nasal cannula with her oxygen concentrator set at 5 Liters. R8's Oxygen concentrator was plugged into a pink extension cord laying on top of her bedside dresser. On 10/15/24 at 11:57 AM R8 stated I have to wear Oxygen all the time. I can't go without it at all. The girls (staff) will plug me in wherever. I had someone bring in my pink extension cord so that I could plug in my phone and my small refrigerator. There are not enough plug ins in this room. On 10/17/24 at 12:35 PM V14 Maintenance Director stated R8's Oxygen Concentrator should not be plugged into her extension cord. V14 Maintenance Director removed R8's Oxygen Concentrator plug from the extension cord and plugged it directly into a wall outlet. 2.) R18's undated Face Sheet documents medical diagnoses as Chronic Congestive Heart Failure, Interstitial Pulmonary Disease, Protein-Calorie Malnutrition, Lymphedema, Iron Deficiency Anemia, Peripheral Vascular Disease, Epilepsy, Edema, Borderline Intellectual Functioning, Cellulitis of Right and Left Lower Limbs, Kyphosis, Ileostomy status and Chondromalacia Patella. R18's Minimum Data Set (MDS) dated [DATE] documents R18 as cognitively intact. On 10/15/24 at 10:18 AM R18's bed was plugged into a power strip nailed to the wall next to R18's bed. On 10/16/24 at 12:15 PM R18's bed was plugged into a power strip nailed to the wall next to R18's bed. On 10/16/24 at 12:18 PM R18 stated I don't have enough wall plug ins for everything so I have to plug things into the extension cord (pointing to the extension cord nailed to the wall). 34058 3) On 10/15/24 at 2:01 PM, R42's electric bed was plugged into an extension cord power strip, along with a personal unit refrigerator. On 10/17/24 at 12:30 PM V14 Maintenance Director stated all of the resident beds and all medical equipment should be plugged directly into the wall outlets. V14 stated There is too much electrical draw on the extension cords for the beds and medical equipment to be plugged into those. It could be a fire hazard. I do building rounds monthly and have had to move electrical cords before. I tell the staff not to do that but they (staff) do it anyway. On 10/17/24 at 2:15 PM V1 Administrator stated the facility does not have a policy that states medical equipment should not be plugged into extension cords. V1 stated the expectation for staff is to plug all resident beds and medical equipment into the wall outlet for safety.

Based on interview and record review, the facility failed to obtain physician responses from pharmacist recommendations in a timely manner, and failed to develop their pharmacist policy to include timeframes for the steps in the monthly medication regimen reviews. This failure affects two residents (R16 and R44) out of five reviewed for unnecessary medications on the sample list of 43. Findings include: 1. R16's Census Detail dated 10/18/24 documents R16 was admitted to the facility 9/10/24. R16's Hospital Discharge Orders dated 9/10/24 document R16 had a physician ordered prescription for Semaglutide (Rybelsus) (Antidiabetic) 7 milligrams daily. R16's current Physician Order Sheet dated 10/17/24 documents R16's medication Rybelsus did not start until 9/24/24. R16's Consultant Pharmacist (V20) Recommendation dated 9/14/24 documents a notation R16 had a physician order for the medication Rybelsus on R16's hospital discharge record which was not present in the R16's electronic medical record. V20 documented to clarify this with the physician and update the electronic medical record for R16. This same recommendation was not signed by the primary physician until 9/23/24. On 10/17/24 at 12:00 PM, V2, Director of Nursing, stated, The admitting nurse put a checkmark beside that medication on the hospital discharge orders, she must have not known what it is because it doesn't populate in the electronic medical record. She must have put the question mark there and was going to come back to it and just forgot. In anyway, the medication got missed. V2 further stated, We do have a process that a second nurse is supposed to review the admission orders for each resident so things don't get missed. 2. R44's Consultant Pharmacist Recommendations to Nursing dated 4/10/24, V21, Consultant Pharmacist documents R44 has an order for Lorazepam PRN (as needed) without a stop date, according to regulations PRN medications can only be used for 14 days without a physician documenting a rationale for continued use. This recommendation form has checkboxes for a physician response to: 1) discontinue the medication; 2) continue use of the medication for (specify) number of days as the benefits outweigh the risks; and a space for the physician to document a rationale for continued use past the 14 days. This same form documents hospice patients are not excluded from this requirement. R44's electronic medical record contained identical Pharmacist Consultant Recommendations dated 6/12/24, and 8/12/24. None of the three recommendations had a signature, a selected option, nor rationale from a physician. On 10/18/24 at 10:20 AM, V2, Director of Nursing, stated , (R44) is receiving hospice services so it is just a main standard for hospice, but I don't find any response from the doctor about it. V2 then stated, Usually the way these are supposed to work is the pharmacist sends us the recommendations, then I send them to the physicians. The facility policy Consultant Pharmacist Service Provider Requirements dated 1/18/24 does not include any timeframe for the pharmacy medication regimen review process for the facility to obtain a response from the physician.

Based on observation, interview and record review the facility failed to honor one (R260) residents food preferences out of nine residents reviewed for meal service in a sample list of 43 residents. Findings include: R260's undated Face Sheet documents medical diagnoses as Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Orthostatic Hypotension, Dementia, Vitamin D Deficiency, Anemia and Chronic Kidney Disease Stage 3. This same Face Sheet documents R260 admitted to the facility on [DATE]. R260's Minimum Data Set (MDS) dated [DATE] documents R260 as moderately cognitively impaired. R260's Electronic Medical Record (EMR) does not include a food preferences interview. R260's Nutritional careplan was initiated 10/15/2024. R260's Careplan did not include a nutritional focus area, goal nor interventions prior to 10/15/24. R260's careplan intervention dated 10/8/24 documents R260 is of Hindu faith. On 10/15/24 at 12:45 PM R260 was served a Polish sausage, macaroni salad, spinach, chocolate chip cake with a glass of water and a glass of tea for the lunch meal. On 10/15/24 at 1:45 PM R260 stated no staff offered him any alternatives for lunch. On 10/16/24 at 1:02 PM R260 stated he has no medical restrictions on his diet and that he does not eat pork due to his religion. R260 stated I just don't eat it if they bring it. I don't ask for anything else. On 10/16/24 at 3:00 PM V9 Dietary Manager stated all residents should be interviewed to determine their preferences and for any foods that they might not wish to eat based on their religion. V9 stated I have only been here a couple of months and am trying to get everything in order. I had already found that there are problems with these things. There is no list of resident preferences for anyone over the last several months. I am planning on talking to all the residents that admit to the facility and also those that have been here a few months to update their diet slips. Residents should be able to be served foods that they like and they should not be served foods that go against their religion. The facility policy titled Food and Nutrition Services Dining Services dated 9/1/2021 documents the food preference interview will be entered into the medical record. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies and intolerances, and preferences.

Based on observation, interview and record review the facility failed to serve a resident meals consistent with a resident's allergies for one of nine residents (R6) reviewed for meal service in a sample list of 43 residents. Findings include: R6's undated Face Sheet documents medical diagnoses as Diabetes Mellitus Type II, Morbid Obesity, Gastroesophageal Reflux Disease (GERD), Spinal Stenosis, Dizziness and Giddiness, Mild Intellectual Abilities, Fusion of Spine, Major Depressive Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder (PTSD). This same Face Sheet documents R6's allergies as Bupropion, Regadenoson, Tetracycline, Valproic Acid, Buspar, Penicillin and Onion. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R6's Physician Order Sheet (POS) dated October 2024 documents a physician diet order for Consistent Carbohydrate (CCHO) diet, regular texture and thin/regular consistency. R6's undated diet ticket documents R6 is allergic to onions. R6's Care Plan intervention dated 9/9/2024 documents to provide R6's diet as ordered by Physician. On 10/15/24 at 12:23 PM R6 was sitting at a dining room table with lunch meal of polish sausage, macaroni salad with pieces of onion, spinach with pieces of onions and chocolate chip cake sitting on table in front of R6. R6's diet slip documents No Brussels sprouts, cabbage, chowder soup and salt. Allergies: Onion. R6 didn't eat the macaroni salad and spinach. On 10/15/24 at 12:30 PM R6 stated If I eat onions I will go to the hospital. Onions make me throw up and get very sick. On 10/16/24 at 3:10 PM V9 Dietary Manager stated R6's diet ticket documents R6 is allergic to onions and should not have been served any onions. V9 Dietary Manager stated I am glad to see that (R6) did not eat them or she could have gotten very sick. (R6) had a history of being force fed onions as a child so I think that is why it is listed as an allergy but either way she should not have been served any onions. The facility policy titled Food and Nutrition Services Dining Services dated 9/1/2021 documents the food preference interview will be entered into the medical record. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies and intolerances, and preferences.

Based on interview and record review, the facility failed to document evaluations to determine cognitively impaired residents' capacity to consent to a known sexual relationship, failed to develop their policy on intimate resident behavior to include the criteria for initial evaluation and frequency with which a cognitively impaired resident's capacity to consent to an intimate relationship is to be evaluated, and to specify where and how the evaluations and determinations would be documented and maintained. This failure affects two (R1, R2) residents and has the potential to affect 22 additional cognitively impaired residents (R5 through R26) on the sample list of 26 reviewed for cognitive capacity. Findings include: The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships, documents the facility may utilize, as appropriate, a mental health practitioner, psychiatrist, clinical social worker, or psychologist, or primary care physician to help in the evaluation and determination of an individual's ability to provide informed consent. R2's Diagnoses List dated 9/25/24 documents R2's medical diagnoses includes Dementia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 scored a 2 out of a possible 15 during a Brief Interview for Mental Status, rating R2 as severely cognitively impaired. R1's Diagnoses List dated 9/25/24 documents R1's medical diagnoses includes Dementia. R1's MDS dated [DATE] documents R1 received a score of 7 out of 15 during a BIMS, rating R1 as severely cognitively impaired. On 9/25/24 at 1:15 PM, V3, Certified Nursing Assistant (CNA), stated she had direct knowledge of R1 and R2 kissing. On 9/25/24 at 1:25 PM, V5, CNA, stated she had seen R1 and R2 hold hands, and R1 hug R2 around the neck. V5 further stated that another resident reported to V5 seeing R1 in R2's room rubbing on R2's private area (genitals) with her hand. V5 stated she did not think R2 had the capacity to consent to sexual activity. On 9/25/24 at 1:35 PM, V6 CNA, stated she did not think either R1 nor R2 had the mental capacity to form consent to sexual activity. On 9/25/24 at 1:45 PM, V7, Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room. On 9/25/24 at 2:33 PM, V11, Friend/ Power of Attorney (POA) for R2, stated, I am aware of the situation with (R2) in (R1's) room and playing with (R1's) privates (genitals). I absolutely think she (R1) is aware of what she is doing and I think she has the mental thoughts to be able to do that kind of thing and I don't think that is out of line. On 9/25/24 at 2:47 PM, V12, sister/ POA for (R1), stated, Well (R1) was capable of making that kind of decision (whether to engage in an intimate relationship) before he went into the nursing home so I would say he still is capable of making that kind of decision now. On 9/25/24 at 2:55 PM, V2, Director of Nursing, stated, I do know (R1) and (R2) are friendly, I know they used to be at another nursing home at the same time so they have known each other from back before here, I know they sit together at the same table in the dining room, and (R2) stops by (R1's) room to ask if he is going to the dining room. V2 then stated, I do think they both are able to consent to a sexual relationship. V2 concluded by stating, As far as I know there hasn't been any formal documented evaluation of either one of them for a capacity to consent. On 9/25/24 at 3:40 PM, V13, Social Services Director, I have not ever evaluated either of the two of them for the ability to consent to a sexual relationship. On 9/25/24 at 3:40 PM, V14, Regional Director of Operations, stated, There should have been some documentation of both resident's capacity to consent to sexual activity. Going forward, we will make it as right as we can. On 9/27/24 at 10:27 AM, V14 stated, Absolutely (we should have been able to put all of the documentation of the evaluations of R1 and R2's capacity to consent to a sexual relationship in your hand when you came in to do this survey). The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships did not include where and how the results of an evaluation of a resident's capacity to consent to a sexual relationship are to be maintained, nor was there a time interval for the evaluations to be conducted. On 9/27/24 at 2:20 PM, V14, Regional Director of Operations, stated, I don't see that our policy specifies where we would document or maintain the evaluations (of a resident's capacity to consent to an intimate relationship) but going forward we would scan them into the resident's chart. V14 further stated, We would do the evaluations quarterly, we need to set up the form in the PCC (electronic medical record format). On 9/27/24 at 2:20 PM, V17, Regional Director, stated, For now we would just have to scan the evaluations into the medical record. V17 then stated, All I see as far as frequency is as appropriate which isn't very specific. The portion of the policy which V17 referred to documents The facility will record assessment findings in appropriate documentation. There is no mention of the frequency of the assessments or evaluations. Additional residents potentially affected include: R5's MDS dated [DATE] documents R5 received a score of 3 out of 15 during a BIMS, indicating severe cognitive impairment. R6's MDS dated [DATE] documents R6 received a BIMS score of 10 out of 15, rating R6 as moderately cognitively impaired. R7's MDS dated [DATE] documents R7 received a BIMS score of 2 out of 15 during a BIMS, rating R7 as severely cognitively impaired. R8's MDS dated [DATE] documents R8 received a BIMS score of 11, indicating moderate cognitive impairment. R9's MDS dated [DATE] documents R9 received a BIMS score of 4 out of 15, indicating severe cognitive impairment. R10's MDS dated [DATE] documents R10 received a score of 3 out of 15 during a BIMS, rating R10 as severely cognitively impaired. R11's MDS dated [DATE] documents R11 received a score of 6 out of a possible 15 during a BIMS, rating R11 as severely cognitively impaired. R12's MDS dated [DATE] documents R12 could not complete a BIMS interview and was assessed by staff to be severely cognitively impaired. R13's MDS dated [DATE] documents R13 received a score of 11 out of 15 during a BIMS, rating R13 as moderately cognitively impaired. R14's MDS dated [DATE] documents R14 received a score of 11 out of 15 during a BIMS, rating R14 as moderately cognitively impaired. R15's MDS dated [DATE] documents R15 received a score of 11 out of a possible 15 during a BIMS, rating R15 as moderately cognitively impaired. R16's MDS dated [DATE] documents R16 could not complete a BIMS interview and was rated by staff to be severely cognitively impaired. R17's MDS dated [DATE] documents R17 received a BIMS score of 3 out of 15, rating R17 as severely cognitively impaired. R18's MDS dated [DATE] documents R18 received a score of 7 out of 15 during a BIMS, rating R18 as severely cognitively impaired. R19's MDS dated [DATE] documents R19 received a score of 9 out of 15 during a BIMS, rating R19 as moderately cognitively impaired. R20's MDS dated [DATE] documents R20 received a BIMS score of 7 out of 15, rating R20 as severely cognitively impaired. R21's MDS dated [DATE] documents R21 received a BIMS score of 6 out of 15, rating R21 as severely cognitively impaired. R22's MDS dated [DATE] documents R22 received a score of 3 out of 15 during a BIMS, rating R22 as severely cognitively impaired. R23's MDS dated [DATE] documents R23 received a score of 7 out of 15 during a BIMS, rating R23 as severely cognitively impaired. R24's MDS dated [DATE] documents R24 received a score of 9 out of 15 during a BIMS, rating R24 as moderately cognitively impaired. R25's MDS dated [DATE] documents R25 received a score of 10 out of 15 during a BIMS, rating R25 as moderately cognitively impaired. R26's MDS dated [DATE] documents R26 received a score of 7 out of a possible 15 during a BIMS, rating R26 as severely cognitively impaired.

Based on observation, interview and record review the facility failed to protect the resident's right to be free from sexual abuse by another resident and verbal/mental abuse by a staff member for four of seven residents (R1, R2, R3 and R5) reviewed for abuse in the sample list of seven residents. These failures resulted in R2 crying, feeling uncomfortable, and removing herself from shared areas with R1 after R2 was sexually abused by R1 and R5 experiencing feelings of isolation and fear after a staff member verbally/mentally abused R5. Findings include. 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS documents R2 requires staff assistance for transfer into/out of her wheelchair and is able to propel wheelchair independently once seated. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 as independent in bed mobility, transfers, walking less than ten feet and self propels wheelchair for longer distances. R1 and R2's combined Final Incident Report to the State Agency dated 7/8/24 documents (R2) stated (R1) touched her breast in the hallway. On 7/18/24 at 3:50 PM R2 stated R2 was wheeling herself down the hallway when R1 wheeled himself up to R2. R2 stated R1 reached out both of his hands and rubbed up and down on both of R2's breasts firmly several times. R2 stated R1's hands were on the outside of R2's blouse. R2 stated I told him (R1) to stop. I pushed his hands away. I told him that he can't do that. That was embarrassing. I am married. R2 stated R1 said 'I am going to get my yummies' as he was rubbing on R2's breasts. R2 was tearful and crying during interview. R2 was wiping tears away from her cheeks and using tissue to blow her nose. R2 stated R2's husband is very ill. R2 stated I wasn't going to tell my husband but how could I keep that from him. He is my husband. After I told him what (R2) had done, we both cried. We were both so upset about the whole thing. R2 stated They (facility) told me that he wasn't coming back after they sent him to the hospital. But now he is back. I don't want to leave. I want him to leave. If I see (R1), I turn around and go the other way. Now I always have to worry about where he is at. No woman is safe when he is here. On 7/19/24 at 1:30 PM V10 Licensed Practical Nurse (LPN) stated R2 reported to V10 on 6/30/24 that R1 had rubbed up and down on R2's breasts and said 'I am going to get my yummies'. V10 stated I called (V2) Director of Nurses (DON) who instructed me to call the police, make all the notifications and put (R1) on continual observations. A few hours later (R1) was sent to the emergency room due to a change of condition not related to his behaviors. On 7/19/24 at 3:42 PM V1 Administrator stated R1 should have never been allowed to inappropriately touch R2. V1 stated Unfortunately, that is considered sexual abuse if both parties are not willing. (R2) was not willing. We (facility) have already started inservicing our staff. 2.) R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents R3 requires assistance with transfers and is able to propel self in her wheelchair. R1's Nurse Progress Note dated 6/29/24 at 2:58 PM documents (R1) attempting to touch staff and residents inappropriately, stating he is going to touch the female nurses. (R1) stating he wants the nurse to get down on her knees for him. Touching a Certified Nurse Aide (CNA) on their buttocks. (R1) stating all women need a man. Educated (R1) multiple times. Stating (R1) might have to get sent out (emergency room ), (R1) stated he doesn't care. R1's Nurse Progress Note dated 6/29/24 at 4:15 PM documents (V1) Administrator notified of (R1) trying to touch staff and residents. (V1) stated to keep (R1) away from women and take two staff into room with (R1) for any care. On 7/19/24 at 10:50 AM R3 stated R3 was wheeling herself towards the exit door at 2:50 PM on 6/29/24. R3 stated I know it was ten until 3:00 PM because I was going out with the smokers. I don't smoke but I like to sit outside a lot. (R1) rolled right up to me and started to grab at my Left Breast. I batted his arms away and he ended up grabbing my arm. That didn't hurt or anything. (R1) just grabbed my arm to stay close to me because he was still trying to grab at my breast. (R1) had his hand cupped when he was grabbing at me. Like it was the shape of my breast. I told him to go away. I told him to stop it and he can't do that. (V13) Certified Nurse Aide (CNA) saw that happen. Well, he went on down the hall and I went outside. As we were coming back inside, I went to the dining room. (R1) rolled up to me in the dining room and tried to do the same exact thing. This was about 3:30 PM. I batted him away again and he left the dining room. I reported that incident also to (V4) LPN. I will not go to the dining room if (R1) is in there. I like activities and I like to talk to people but I will just stay in my room when (R1) is on the loose. I am not scared of (R1) but that made me feel very vulnerable and uncomfortable. It really shook me up. If (R1) is trying to touch women who are alert and oriented, what is he trying to do with those that aren't? On 7/18/24 at 1:50 PM V13 Certified Nurse Aide (CNA) stated V13 witnessed R1 approach R3 in his wheelchair in the hallway. V13 stated R1 attempted to grab at R3's Left Breast and R3 'swatted' R1 away. V13 stated R1 grabbed R3's Left Arm in an attempt to grab at R3's Left Breast. V13 CNA stated both residents (R1, R3) were separated and this incident was reported to V4 Licensed Practical Nurse (LPN). V13 stated R1 was placed on a one to one (continual monitoring) the next day (6/30/24) after R1 touched R2's breasts. On 7/19/24 at 1:25 PM V10 Licensed Practical Nurse (LPN) stated R3 reported to V4 LPN and V10 on 6/29/24 that R1 had attempted to touch her Left Breast in the hallway just before the afternoon smoke break on 6/29/24. V10 stated R3 said R1 did not touch her breast but did attempt to. On 7/19/24 at 3:40 PM V1 Administrator stated V1 never received any calls on 6/29/24. V1 stated V1 did receive a call on 6/30/24 and referred staff to call V2 Director of Nursing (DON). V1 Administrator stated R1 should have been placed on continual observations on 6/29/24 right after the first attempt at inappropriately touching R3's Left Breast. 3.) R5's undated Face Sheet documents R5's medical diagnoses as End Stage Renal Disease, Right Below the Knee Amputation, Diabetes Mellitus Type II with Neuropathy, Chronic Pulmonary Edema, Renal Osteodystrophy, Post Traumatic Stress Disorder and dependence on Renal Dialysis. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 as dependent on staff for assistance with toileting, dressing, bathing, personal hygiene, transfers and mobility. R5's Electronic Medical Record (EMR) documents R5 utilizes a total body mechanical lift for transfers. On 7/18/24 at 11:45 AM R5 stated A couple of weeks ago (V8) Certified Nurse Aide (CNA) cussed me out like a dog. (V8) told me that if I was going to keep turning on my call light that she would put my f****** a** (expletives) in a chair and make me sit in the f****** (expletive) hallway. (V8) is a night shift CNA that always comes in my room and cusses at me. R5 stated I put on my call light to see if someone could get me a can of soda out of the machine. (V8) Certified Nurse Aide (CNA) came in, turned off my call light. I asked (V8) if she would take my debit card to get me a soda and she refused. Then I asked (V8) if she could get me up so that I could roll down to the vending machine myself and get a soda. (V8) CNA said 'Get up your f****** (expletive) self'. So I said 'OK. I will. I will just crawl down there on my own.' That is when (V8) said 'This ain't no f****** (expletive) hotel. You can get that your f****** (expletive) self. R5 stated R5 is scared of V8 CNA. R5 stated It is just (V8) and me in the middle of the night. I don't want to make her mad because who knows what (V8) will do. (V8) already just left me in my chair. I can't get up on my own. I had to just sit there until the next shift showed up a few hours later. I was afraid to ask (V8) to do anything else that night so I just sat there. On 7/18/24 at 12:15 PM V8 Certified Nurse Aide (CNA) stated V8 regularly cares for R5. V8 CNA stated (R5) asked for a block of cheese one night and I told him no because the kitchen was running out of cheese because of him. (R5) is alert and oriented and repeatedly doesn't follow his orders. (R5) is on Dialysis and just had his lower Right Leg amputated so he needs our help for most things. (R5) is so fat because he just sits around all the time. The last thing (R5) needs is soda and cheese. (R5) knows better and just rings for staff to do everything for him. I am not going to help someone who can do things for themselves. I did refuse to take his Debit card and I told (R5) he didn't need any kind of sodas. (R5) asked me to get him up and I said no because he doesn't need any soda in the middle of the night. (R5) said 'I am going to just crawl there' and I told him 'Go ahead and crawl then. See how far you get.' I don't remember ever using foul language but I did tell (R5) that this wasn't a hotel and he needs to do things for himself instead of bothering the staff. (R5) asks for things he knows he shouldn't have. On 7/19/24 at 3:45 PM V1 stated V8 Certified Nurse Aide (CNA) should have provided the cares R5 requested. V1 Administrator stated (R5) is alert and oriented. If (R5) asks the staff to get him up into his wheelchair, then they should do that. (V8) should never have used any profanity or bad attitude towards (R5). That is not acceptable. The facility policy titled 'Abuse Policy' revised 1/9/24 documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The is facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse is the non-consensual sexual contact of any type with a resident. Non-consensual is defined as one of the following: 1. The resident may welcome the act, but the resident lacks the ability to consent, 2. The resident does not want the contact, 3. Resident is unconscious/comatose, 4. Resident is sedated. This abuse includes, but is not limited to, unwanted intimate touching of any kind (especially of the breast or perineal area), sexual harassment, sexual coercion, sexual assault such as rape, sodomy, or coerced nudity. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident.

Based on observation, interview and record review the facility failed to protect residents (R2, R3) from inappropriate behaviors and sexual abuse by another resident (R1) after an abuse allegation. This failure affects three of seven residents (R2, R3 and R1) reviewed for abuse in the sample list of seven. This failure resulted R2 crying, feeling uncomfortable, and removing herself from shared areas with R1 after R1 was left unsupervised and R1 sexually abused R2. Findings include: The facility policy titled 'Abuse Policy' revised 1/9/24 documents the facility is committed to protecting residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone. The policy also states the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse is the non-consensual sexual contact of any type with a resident. Non-consensual is defined as one of the following: 1. The resident may welcome the act, but the resident lacks the ability to consent, 2. The resident does not want the contact, 3. Resident is unconscious/comatose, 4. Resident is sedated. This abuse includes, but is not limited to, unwanted intimate touching of any kind (especially of the breast or perineal area), sexual harassment, sexual coercion, sexual assault such as rape, sodomy, or coerced nudity. 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS documents R2 requires staff assistance for transfer into/out of her wheelchair and is able to propel wheelchair independently once seated. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 as independent in bed mobility, transfers, walking less than ten feet and self propels wheelchair for longer distances. R1's Nurse Progress Note dated 6/29/24 at 2:58 PM documents (R1) attempting to touch staff and residents inappropriately, stating he is going to touch the female nurses. Educated (R1) multiple times. Stating (R1) might have to get sent out (emergency room ), (R1) stated he doesn't care. On 7/18/24 at 3:55 PM R2 stated R1 rubbed both of his hands over R2's breasts several times on 6/30/24. R2 stated I heard (R1) did something to another resident (R3) the day before he fondled my breasts. They (facility) sent (R1) to the hospital. They (facility) told me that he wasn't coming back. But now he is back. I don't want to leave. I want him to leave. (R1) just roams around. If I see (R1), I turn around and go the other way. Now I always have to worry about where he is at. No woman is safe when he is here. R2 was tearful and crying during the interview. On 7/19/24 at 3:42 PM V1 Administrator stated R1 should have been placed on continual observations on 6/29/24 right after the first attempt at inappropriately touching R3's Left Breast. V1 stated That really put our residents at risk. I was on medical leave that weekend so I was not aware that (R1) was not on continual observations. (R1) should have been (on continuous observations) to help prevent any further incidents from happening. 2.) R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents R3 requires assistance with transfers and is able to propel self in her wheelchair. On 7/19/24 at 10:50 AM R3 stated R1 attempted twice to touch R3's Left Breast inappropriately on 6/29/24. R3 stated (V13) Certified Nurse Aide (CNA) saw it happen the first time. R3 stated I told (R1) to stay away and not to do that when (R1) tried to touch my breast the first time. Then (R1) wheeled up to me and tried to do it again about 40 minutes later. I think they (staff) should have been watching him closer. R3 stated I will not go to the dining room if (R1) is in there. I like activities and I like to talk to people but I will just stay in my room when (R1) is on the loose. I am not scared of (R1) but that made me feel very vulnerable and uncomfortable. It really shook me up. If (R1) is trying to touch women who are alert and oriented, what is he trying to do with those that aren't? On 7/18/24 at 1:50 PM V13 Certified Nurse Aide (CNA) stated V13 witnessed R1 attempt to grab at R3's Left Breast and R3 'swatted' R1 away. V13 stated R1 grabbed R3's Left Arm in an attempt to grab at R3's Left Breast. V13 stated R1 was placed on a one to one (continual monitoring) the next day (6/30/24) after R1 touched R2's breasts. On 7/19/24 at 3:40 PM V1 Administrator stated V1 never received any calls on 6/29/24. V1 stated V1 did receive a call on 6/30/24 and referred staff to call V2 Director of Nursing (DON). V1 Administrator stated R1 should have been placed on continual observations on 6/29/24 right after the first attempt at inappropriately touching R3's Left Breast. V1 stated residents were at risk of being abused by R1 when the facility was aware that R1 was having inappropriate sexual behaviors and did not send R1 to the emergency room for evaluation and/or place R1 on continual monitoring immediately after the first incident with R3.

Based on observation, interview and record review the facility failed to provide adequate supervision to prevent a resident from leaving the building resulting in a fall outside on the sidewalk (R52) and failed to remove a mechanical lift sling from underneath a resident to prevent sliding in the wheelchair (R18) for two of eight residents (R52, R18) reviewed for accidents in the sample list of 34. This failure resulted in R52 exiting the building unaccompanied and falling resulting in abrasions to R52's face, hand and knee and a bruise to R52's face. Findings include: The facility's Accidents and Incidents policy with a revised date of 9/7/23 documents, Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and incidents. Policy: All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. 1.) R52's Order Summary Report dated 10/31/23 documents diagnoses including Orthostatic Hypotension, Personal History of Transient Ischemic Attack, Other Specified Disorders of the Brain, Vascular Dementia, Adjustment Disorder With Depressed Mood, Suicidal Ideations, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Auditory Hallucinations, Other Seizures, Mild Cognitive Impairment of Uncertain or Unknown Etiology and Repeated Falls. This Order Summary documents an order for an electronic alert device placement every shift for monitoring and an order to check the function of the device every shift with an order date of 10/10/23. R52's Nurse's Note dated 9/5/23 at 9:27 AM documents R52 was exit seeking and electronic alert device was placed to R52's left leg. This note documents R52 stated R52 wanted to walk outside. R52's Nurse's Note dated 9/6/23 at 8:43 AM documents R52 removed the electronic alert device at breakfast and Social Services was made aware. R52's Nurse's Note dated 10/10/23 at 9:47 AM documents that staff noticed R52's electronic alert device sitting on the bedside stand. This note documents R52 stated R52 bit it off of R52's wrist. This note then documents the Social Services Director was able to talk R52 into putting the electronic alert device back on R52's wrist. R52's Nurse's Note dated 10/26/23 at 2:00 PM documents the nurse was alerted by staff that R52 was outside on the ground by the smoking area. R52 was non-compliant with fall alarm and electronic alert device and was walking without assistance resulting in a fall. Assessment showed abrasion to the right knee, a bruise to the left middle back, a skin tear to the right great toe and right hand, and bruising and an abrasion to the left temple and cheek. R52's Minimum Data Set (MDS) dated [DATE] documents R52 is moderately cognitively impaired and requires assistance of one staff member for ambulation. This MDS documents that R52's balance is not steady when walking, that R52 can only be steady with staff assist. R52's Care Plan dated 9/5/23 documents R52 has a potential risk of elopement, cognitive deficit, exit seeking behavior (with purpose to leave), history of elopement, history of wandering, repetitive pacing (ambulatory), walks or wheels about aimlessly w/o (without) purpose. This Care Plan has interventions dated 9/5/23 to place an electronic sensor device to alert staff of exit attempt (or if unavailable place on 1:1 observation), check placement device, check battery function and evaluate effectiveness. Monitor whereabouts regularly, recognize any unsafe conditions or escalating patterns and respond to any alarm activation promptly. On 10/30/23 at 9:55 AM, R52 was in R52's bed sleeping. R52 had a bruise on R52's left eye. There was a mat on the floor and a pressure alarm on the bed. On 10/30/23 at 3:01 PM, R52 was in R52's wheelchair outside smoking. There was a staff member outside with R52. On 10/31/23 at 12:35 PM, R52 was in R52's bathroom with the door open. R52's wheelchair was sitting outside of the bathroom door and the pressure alarm was sitting in the wheelchair not sounding. V6 Certified Nursing Assistant was notified and immediately went to assist R52. V6 stated that R52 turns off the pressure alarm so they do not know when R52 gets up. R52's Fall report dated 10/26/23 documents the nurse was notified of R52 being found on the ground face first. Nurse assessed R52 and addressed skin impairments and applied first aid. Nurse located electronic alert device and placed it to R52's right ankle and all staff were notified to check the placement of the electronic alert device. On 10/31/23 at 3:05 PM, V26 Certified Nursing Assistant stated that when R52 fell on [DATE] V26 was the only CNA working on R52's hall and V26 did not see R52 leave. V26 stated that R52 removed the electronic alert device and left it in R52's room and rolled the wheelchair to the front door, stood up and pushed the button to turn off the door alarm and walked out the door. V26 stated that R52 walked around the building to the smoking area and R52's shoe slipped off when R52 got to the grass area and R52 fell face first into the concrete. V26 stated that another resident's family was outside with that resident and found R52. V26 stated no one in the facility knew that R52 had gotten outside alone. V26 stated that if that family hadn't found R52 who knows how long R52 would have laid out there. On 11/1/23 at 2:52 PM, V2 Director of Nursing stated regarding R52's fall on 10/26/23 that V2 can't speak to the fact of whether R52 had the electronic alert device on or not as V2 was not in the building at the time of the fall. V2 confirmed that R52 exited out the front door and got out without anyone knowing R52 left the building. V2 confirmed R52 should not have been outside by R52's self. V2 confirmed that R52 has removed the electronic alert device multiple times and they replace it when they find it. On 11/1/23 at 2:58 PM, V1 Administrator confirmed that another resident's family found R52 outside after R52 had gotten out of the building and fell . V1 confirmed that R52's current black eye is from the fall on 10/26/23 and V1 confirmed that R52 was not supposed to be outside alone. On 11/1/23 at 3:04 PM, R52 stated on 10/26/23 when R52 fell , R52 went out the front door of the facility and walked through the parking lot to the smoking area and when R52 got to the grass area R52's shoe got caught on the grass and R52 tripped and fell and hit R52's face on the concrete sidewalk. 35046 2.) R18's care plan with a revision date of 10/30/23 documents R18 is at risk for falls and injuries related to impaired balance and mobility. This care plan includes an intervention for a mechanical lift. On 10/30/23 from 12:12 PM to 12:29 PM, R18 was sitting in the dining room. R18 complained multiple times that he was sliding down in the wheelchair. R18 was noted to be sitting on a pressure relief cushion. A mechanical lift sling was positioned under R18's buttocks and on top of the pressure relief cushion. The sling was noted to be bunched in places. V6 Certified Nurse's Assistant assisted R18 with re-positioning in the wheelchair. On 11/01/23 at 2:51 PM, V6 stated she helped R18 with repositioning in the dining room on 10/30/23. V6 stated the mechanical lift sling lying on top of the pressure relief cushion did cause sliding of the sling. The facility's mechanical lift policy with a revision date of 1/23/23 documents instructions to remove the mechanical lift sling from underneath the resident after transferring the resident. On 11/1/23 at 11:40 AM, V19 Director of Operations stated she thinks the mechanical lift sling is supposed to be removed after transfer for the prevention of pressure. When asked if it was also to prevent residents from slipping out of the wheelchair, V19 stated yes. At 11:50 AM, V19 stated she called the person who made the policy and they have now amended the policy a few minutes ago to state that they only remove the sling when transferring to bed. V19 verified that the amended policy was not changed until it was questioned and that it used to say to remove the sling after transfers.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free of physical and mental abuse by another resident for one of six residents (R4) reviewed for abuse in a sample of six. This failure caused (R4) to experience psychosocial harm including fear, feeling unsafe, and feeling uncomfortable. Findings include: The facility's abuse prevention policy (not dated) states Resident have the right to be free of abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods, services that are necessary to attain and/or maintain physical, mental, and psychosocial well being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. R4's Order Summary printed 9/6/23 at 1:56PM documents the following diagnoses: Dissociative and Conversion Disorder, Depression, Bipolar Disorder, Generalized Anxiety Disorder, and Borderline Personality Disorder. R4's Follow-up Psychiatric Evaluation dated 8/14/23 by V5 Advanced Practice Nurse,Certified Nurse Practitioner (APRN,CNP) documents R4 appears groomed, psychomotor activities are within normal limits. Speech is Normal. Behavior is cooperative. Mood is ok. Affect is euthymic. Flow of thought is logical. Content of thought is within normal limits. Oriented to place, person,time,and situation. Memory is good. Insight and judgement is good. Intellect is average. Sleep is within normal limits. This evaluation also documents (R4) does not care much for her new roommate. R4's Minimum Data Set (MDS) dated [DATE] documents R4 scored a 15/15 on her Brief Interview of Mental Status (BIMS) assessment indicating that R4 is cognitively intact. R3's Care Plan updated 8/30/23 documents (R3) has visual and auditory Hallucinations where she has episodes where she hears and sees children across the hall getting hurt or people outside her window using switch blades. (R3) also has episodes of throwing water on roommate when she believes that her roommate is going to kill her. this is all related to R3's diagnoses of Bi-Polar Disorder and Schizophrenia. R3's progress note dated 8/22/23 at 1:55AM documents (R3) threw cup of water on her roommate (R4) because (R3) states that 'her roommate threatened to kill her.' (R4) then states that '(R3) is going to shove something down her roommates (R4's) throat.' (R3) then states she 'is going to call her two lawyers in the morning.' Action: Moved resident to room by herself. Called the administrator to report the incident. Response: Resident more calm and has settled down. On 9/6/23 at 1:00PM R4 was lying on her bed watching TV. When asked if she has ever felt unsafe at the facility R4 stated Well I got a new roommate who slept in the recliner chair. (R4 pointed to recliner in room.) We really didn't get along and I told staff that. I was afraid of (R3). (R3) imagined things and made me nervous. One night at 1:30 AM I was sound asleep and (R3) threw a whole big cup (pointed to 32 ounce water container) of iced water on me. Can you imagine someone doing that when you are sleeping? She accused me of trying to kill her and her husband and said she would have her son come after me. I was really scared. I couldn't sleep for a few nights after that. They took (R3) out of the room, but I knew (R3) was somewhere else in the nursing home and I was worried (R3) would come in and do something. I was told (R3) is gone now and I feel better. R4 avoided eye contact and bit her lower lip while talking. R4 clenched her hands together as she recalled the incident. On 9/6/23 at 1:30PM V2, Director of Nursing (DON) stated I don't think we were aware (R3 and R4) did not get along as roommates. V2 verified the issues concerning R4's roommate was addressed in R4's Follow-up Psychiatric Evaluation dated 8/14/23.

Based on observation, interview, and record review, the facility failed to ensure safe mechanical lift transfers for two of four residents (R1 and R4) reviewed for accidents in the sample list of four residents. Failing to safely position R1 when using the sit-to-stand mechanical lift resulted in R1 sustaining a laceration requiring 13 sutures. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as requiring total dependence of one person for transfers, extensive assistance of two people for bed mobility, dressing, toileting, and extensive assistance of one person for personal hygiene. R1's Nurse Progress Note dated 8/11/23 at 2:57 PM documents, Called to (R1's) room around 8:00 AM. (R1) noted laying on the floor on his back. Staff report (R1's) knees buckled and he slid out of the mechanical lift. Staff had to lower (R1) to the floor but (R1) panicked and grabbed the sit-to-stand (lift) and R1's arm got hooked on the hook where the sling attaches and went through the skin, and it ripped when lowered to the floor. Large laceration noted. 911 notified for transfer to local hospital. R1's Hospital Record dated 8/11/23 documents reason for visit was Arm Laceration. This same report documents R1's Right Upper Inner Arm Laceration as a Large complex skin tear to the Right Medial Upper Arm involving skin and subcutaneous tissues. R1 will be placed on antibiotic due to the dirty nature of the wound. This same report documents R1 required 13 sutures to repair the Right Upper Medial Arm Laceration. R1's Final Incident Report to the Illinois Department of Public Health (IDPH) dated 8/17/23 documents R1 was using the mechanical lift (sit-to-stand lift) for transfer. R1 did not place hands in the proper position and when the mechanical lift raised, it caught (R1's) sweatshirt and caused a skin tear to (R1's) Right Arm. R1 was sent to the emergency room for evaluation. R1 received 13 stitches. Staff were in serviced on mechanical lift. The facility acknowledges the incident took place and has taken the appropriate steps for incident. R1 stated was holding onto the mechanical lift on the outside instead of the inside and this is how R1's sweatshirt got caught. On 8/28/23 at 9:50 AM, V16 (Physical Therapist) stated, I have been working with R1 for a long time now to try to regain some independence and mobility. I recommended that R1 use a mechanical lift for pivot transfers while ensuring his hands/arms are inside the front handlebars. I recommended that R1 grab the back of the mechanical lift and pull himself up without moving the bars themselves. The staff (V3, V4) Certified Nurse Aides (CNAs) could not have transferred R1 correctly. You can tell by the location of R1's right inner upper arm wound. If the staff (V3, V4) would have transferred R1 correctly then his inner right arm would never have been exposed to the hook. On 8/28/23 at 10:20 AM, V1 (Administrator) stated, We (facility) are unable to find any mechanical lift training that would have been provided by the facility to (V3, V4) Certified Nurse Aides (CNAs). I cannot confirm that V3 and V4 ever had training. On 8/28/23 at 11:15 AM, V11 (Nurse Practitioner/NP) stated, The recommendation made by therapy would be consistent with trying to provide as much independence as possible. I realize the therapy recommendation may go against the mechanical lift manufacturer guidelines and the facility policy, but sometimes we (staff) have to look at what is best for the resident. R1 admitted using a total body mechanical lift and has graduated up to a (stand) mechanical lift. The staff (V3, V4) Certified Nurse Aides (CNA) could not have followed the recommendations made by therapy and approved by (V11). R1 would have had to turn his arm inside out to get an injury to the inner part of R1's right arm if he had his hands/arms inside the mechanical lift. V11 stated, Now R1 has to use a total body mechanical lift again with staff which could set him back a great amount. This all could have been prevented if V3, V4 would have provided a safe transfer for R1 to begin with. On 8/28/23 at 4:00 PM, V4 (CNA) stated, The day R1 almost fell and got that huge laceration from the mechanical lift was the worst day. I will always remember that day. V3 and I were transferring R1 when he said he had been incontinent. V3 and I got the supplies to get R1 cleaned and situated. We (V3, V4) assisted R1 back onto the mechanical lift and raised up in the air when R1 said he was weak. I was just getting R1's wheelchair in place when R1 started to fall. I caught R1 so he didn't fall and hit his head. R1's right arm sleeve of his sweatshirt got caught on the hook of the mechanical lift. When I tried to take (R1's) sweatshirt off to free him from the lift, I saw that the hook went through the sweatshirt and tore up his arm. I guess therapy did some training awhile back with the staff, but I never was trained by therapy or anyone else. I have not received any training on how to use mechanical lifts from this facility. 2. On 8/28/23 at 12:00 PM, observed V14 and V19 (Certified Nurse Aides/CNAs) transfer R4 using a stand mechanical lift. V14 and V19 (CNAs) assisted R4 with positioning into the mechanical lift. V14 and V19 did not utilize the leg strap when transferring R4. V14 and V19 (CNAs) positioned R4 in the stand mechanical lift in the hallway next to the nurse's station, then rolled the mechanical lift carrying R4 into bathroom two doors down from nurse's station. On 8/28/23 at 12:20 PM, V14 (CNA) stated, I have never seen any kind of leg strap. Are we (staff) supposed to use those? I have never used one of those when transferring R4. I didn't know we (staff) were not supposed to roll the mechanical lift either. The bathrooms are too small to fit the mechanical lift and the wheelchair and the staff inside. R4's room does not have a bathroom. This is the largest resident bathroom we (facility) have. I guess we could offer R4 a commode or something. The facility policy titled 'Using a Mechanical Level II' revised 1/23/23 documents the facility will utilize mechanical lifts safely per manufacturer guidelines. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. The Undated Best Stand 600 Mechanical Lift Sit to Stand Lift Model SA600 Manufacturer Guidelines documents Place sling behind seated resident with the two red pads under the arms. Cross the adjustable chest belt over and fasten it securely using the buckle. Cross the short black strap over and pull the left loop strap through the black strap. Hook the two loop straps to the hooks on the lift boom using the same hook and loop sequence on each side. The black strap should loop around both shoulder straps and will be straight across in front of resident to stabilize the sling during lifting. Have resident grasp the arms of the boom and tilt head back slightly. Make sure the resident's feet are firmly on the platform and knees are touching the kneepads with kneecaps just above the padding. Use the lift to complete the lift and pivot transfer. The resident lift should be used solely for transferring a resident from one utility (bed, chair, toilet) to another. The resident lift should not be used for transporting or moving any resident from one location to another location. No modification of this equipment is allowed. Fitting the knee belt: Pull open to /velcro. Slide the velcro though slots. Wrap the velcro around the slot and press the velcro together. Check to make sure the belt is strapped to the kneepad. Repeat for the other side. Make sure the pad is facing the back of lower legs. Adjust the strap on the belt buckles to fasten the knee belt and for comfort.

Based on observation, interview and record review, the facility failed to supervise and implement fall interventions for a resident (R45) resulting in a fall with major injury. The facility also failed to maintain safe positioning of a resident's (R10) wheelchair during transfer. This failure affects two residents (R45, R10) of seven residents reviewed for accidents in a sample list of 27 residents. R45 sustained contusions (bruises) and a scalp laceration requiring 12 sutures from an unsupervised fall at the facility. Findings include: 1.) R45's undated Face Sheet documents medical diagnoses of Dementia without Behavioral Disturbance, Metabolic Encephalopathy and History of Falling. R45's Minimum Data Set (MDS) dated [DATE] documents R45 is moderately cognitively impaired. This same MDS documents R45 requires extensive assistance of two people for bed mobility, transfers, dressing and toileting. R45's Fall Risk assessment dated [DATE] documents R45 as a high fall risk. R45's Care Plan intervention dated 7/13/22 documents keep personal belongings within reach. R45's Nurse Progress Note dated 11/13/22 at 11:24 AM documents R45 observed on the floor bleeding from the head. R45 stated that R45 was sitting on the bed and leaned over and fell . Per R45's roommate (R42), R45 was sleeping on the side of bed and fell over. Emergency services were called immediately. Noted laceration on top of scalp and abrasion. Pressure applied to stop the bleeding. Emergency services arrived and R45 sent to emergency room . R45's emergency room Discharge Instructions, dated 11/13/22, documents R45's diagnoses as: Fall, Head Injury, Contusion of Right Eye, Scalp Laceration and Shoulder Contusion. R45's Fall Investigation dated 11/13/22 documents R45 observed on floor with bleeding from scalp. Upon entering room, R45 sitting with back against the bed, legs extended. This same report documents R45 stated 'was sitting on bed, leaned over to grab something and fell over hitting head'. This same report documents injury type: laceration to top of scalp. This same report documents R45 has intermittent confusion at times and was sent to emergency room for evaluation and treatment. This same report documents R45 obtained 12 sutures to top of head from a fall. On 12/6/22 at 12:30 PM, R45 sitting on side of R45's bed looking down at box of tissues sitting on floor. R45 had facial bruising on forehead and under both eyes that was gray and yellow colored. On 12/7/22 at 1:00 PM, R45 sitting on side of bed with no shoes or socks on feet. R45 did not have a bedside table in the room. R45's personal belongings were placed in an open closet and in a chair sitting next to the bed. On 12/7/22 at 2:20 PM, V7 (Certified Nurse Aide/CNA) stated R45 falls frequently. V7 stated, Sometimes R45 knows what is going on but most of the time (R45) needs a lot of supervision and reminders to not fall. On 12/8/22 at 10:00 AM, V2 (Director of Nursing/ DON) stated, We (facility) are really unsure how R45 fell . R45'snfall on 11/13/22 was unwitnessed by staff. R45's roommate (R42) stated (R45) was sitting on the side of (R45's) bed, fell asleep and then fell over hitting his head. R45 told us (facility) that he was sitting on the side of his bed, leaned over to pick something up off of the floor and fell over. Either way, R45 ended up with 12 sutures in R45's head. This fall could have been prevented if the staff were watching (R45) closer. We (facility) should have seen that R45 was either falling asleep on the side of the bed which is dangerous or that R45 should have had all the personal items within (R45's) reach. We (facility) do not know when the last time (R45) was checked on prior to the fall. (R45) has had a ton of falls, so we (facility) need to be watching R45 like a hawk. On 12/9/22 at 11:00 AM, V6 (Licensed Practical Nurse/LPN) stated I was R45's nurse the day he fell and got stitches in his head. R45 is supposed to have all of his belongings within reach, and he did not because he does not have a bedside table. R45 did reside on another hall and had a bedside table but for whatever reason R45's bedside table did not get transferred over here with him. R45's orientation is come and go. Some days (R45) is sharp and other days he needs a lot of supervision. I had several other very ill residents that day and was not able to keep close supervision of R45 like he needs. The staff are very good, but they (CNA's) were busy helping me with the other ill residents when this happened. 2.) R10's undated Face Sheet documents medical diagnoses of Emphysema, Dysphagia, Vascular Dementia, Restless Leg Syndrome and Chronic Pain. R10's Minimum Data Set (MDS) dated [DATE] documents R10 is moderately cognitively impaired. This same MDS documents R10 requires extensive assistance of one person for transfers, bed mobility and personal hygiene. R10's Care Plan dated 10/27/22 documents a bruise to Left Lower Extremity with intervention to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. This same care plan documents an intervention to keep environment clutter free. R10's Facility Incident Investigation dated 10/27/22 documents, V16 (Certified Nurse Aide/CNA) reported to nurse that R10's wheelchair fell over and hit R10's left lower extremity. Noted bruise to area. (R10) stated 'the wheelchair fell on my leg when I was sitting in recliner.' This same report documents root cause: R10 was putting recliner footrest down and hit the wheelchair, which tipped and fell on R10's feet. Intervention: encourage (R10) not to leave wheelchair next to the recliner. R10's Nurse Progress Noted dated 10/28/22 at 2:02 PM, documents V15 (Nurse Practitioner/NP) came to see R10 regarding wheelchair bumping R10's leg when it fell over and bruise to Left Lower Extremity (LLE). New order received to obtain Left Ankle X-Ray complete. On 12/7/22 at 11:30 AM, R10 stated That girl V16 (Certified Nurse Aide/CNA) was trying to help me get out of my recliner. V16 did not watch where my wheelchair was. V16 just came in and pushed my recliner footrest down and it made the wheelchair fall on my legs. It hurt a bit and left a small bruise. V16 should have been more careful. On 12/8/22 at 10:30 AM, V6 (LPN) stated R10 was sitting in R10's recliner when the (V16) Certified Nurse Aide (CNA) pushed down on the footrest of R10's recliner chair. This made the wheelchair tip over onto V16 and R10' legs and feet. The handle of the wheelchair is what hit R10's legs and feet. There was a bruise on R10's left lower leg. V16 should have been more careful and made sure the wheelchair was out of the way so R10 would not have gotten hurt. On 12/8/22 at 2:30 PM, V2 (DON) stated that R10 did not push down her own footrest as the fall investigation documents. V2 stated, V16 (CNA) actually pushed down the footrest, not (R10). The fall investigation report should have been modified. V16 should have made sure to move the wheelchair out of the way of the footrest. That would have solved the problem. Instead, R10 ended up with a bruise because V16 did not think ahead and try to protect the resident.

Based on observation, interview and record review, the facility failed to provide care and services to promote healing of pressure sores. The facility failed to transcribe and implement physician orders, failed to implement care plan interventions for pressure sore prevention, and failed to obtain physician orders for skin issues and ensure pressure wound treatments were being completed as ordered for three of three residents (R29, R56, R259) reviewed for pressure sores in a sample list of 27 residents. The facility failed to promote healing of R259's pressure sore by failing to implement pressure relieving interventions for R259's left foot pressure sore which subsequently progressed from a stage three to a stage four pressure sore. Findings include: 1.) R259's undated Face Sheet documents R259 was admitted to facility on 10/20/22 with medical diagnoses of Anemia in Chronic Kidney Disease, Atrial Fibrillation, Idiopathic Peripheral Autonomic Neuropathy and Osteomyelitis of the Left Foot and Ankle. R259's Electronic Medical Record (EMR) does not document R259 was admitted to the facility with a Left Medial Foot pressure ulcer. R259's Minimum Data Set (MDS) dated [DATE] documents R259 as cognitively intact. This same MDS documents R259 as requiring extensive assistance of two people for bed mobility, transfers, dressing and personal hygiene. R259's Initial Wound Evaluation and Summary report dated 10/26/22 documents R259's Left Medial Foot Pressure Ulcer as a Stage 3. R259's Wound Evaluation and Management Summary dated 11/8/22 documents R259's Left Medial Foot Pressure Ulcer as a deteriorated Stage 3 due to larger size. R259's Care Plan dated 11/8/22 documents heel protectors at all times. This same Care Plan documents to float R259's heels. This same care plan documents an intervention for a pressure redistribution mattress and to assess pressure ulcer weekly by licensed nurse. R259's Wound Evaluation and Management Summary dated 11/16/22 documents R259's Left Medial Foot Stage 4 Pressure Ulcer as deteriorated due to larger size. This same report documents a physician order to cleanse R259's Left Medial Foot Stage 4 Pressure Ulcer and apply Calcium Alginate, absorbent pad and gauze wrap twice daily. This same report documents a physician order for R259 to wear calf high heel protectors at all times. R259's Wound Evaluation and Management Summary dated 11/29/22 documents R259's Left Medial Foot Stage 4 Pressure Ulcer as deteriorated due to larger in size. This same report documents a physician order to cleanse R259's Left Medial Foot Stage 4 Pressure Ulcer and apply Calcium Alginate, absorbent pad and gauze wrap twice daily. This same report documents a physician order for R259 to wear calf high heel protectors at all times. R259's Physician Order Sheet (POS) dated December 1-31,2022 does not document a physician order for R259's Left Medial Foot Stage 4 Pressure Ulcer from 12/2/22-12/8/22. On 12/06/22 at 2:22 PM R259's Left Foot was covered with a white gauze bandage not dated or initialed. R259 was not wearing heel protectors. R259's heels were not floated. R259's bed did not have a low air loss mattress. On 12/07/22 at 2:00 PM, V4 (Licensed Practical Nurse/LPN) completed the dressing change for R259's Left Medial Foot Stage 4 pressure ulcer. R259's wound had a red wound base with approximately 50 percent yellow slough covering base of wound. The peri wound area was dry with moderate dark red color. R259's wound had a previously applied Calcium Alginate dressing well adhered to wound. V4 (LPN) spent several minutes soaking the prior dressing off of R259's wound. R259 showed facial grimacing as V4 LPN was attempting to remove the prior dried on dressing. R259 was not wearing heel protectors. R259's heels were not floated. R259's bed did not have a low air loss mattress. On 12/8/22 at 10:30 AM, R259 was laying on R259's back in bed with both heels laying directly on the sheets. R259 was not wearing heel protectors. R259's heels were not floated. R259's bed did not have a low air loss mattress. On 12/9/22 at 10:30 AM, R259 was sitting up in the wheelchair with R259's Left foot on the foot pedal and Right foot resting on the floor. R259 was wearing ankle high heel protectors. R259's Right foot was dark purple colored and Left foot was purple and white colored. On 12/07/22 at 2:10 PM, V4 (Licensed Practical Nurse/LPN) stated prior to changing R259's Left Medial Foot Stage 4 Pressure Ulcer dressing, V12 (Wound Physician) changed R259's Pressure Ulcer dressing orders 12/6/22 but new order has not been entered into Electronic Medical Record (EMR). On 12/8/22 at 1:00 PM, V2 (Director of Nursing/DON) stated R259 is to be seen weekly by V12 (Wound Physician). V2 stated R259 was not seen by V12 on 11/23/22 due to the holiday. V2 stated We (facility) did not assess R259's Left Medial Foot Stage 4 Pressure Ulcer that week. R259 went from 11/16/22-11/29/22 without having (R259's) wound assessed. That is unacceptable. It had gotten worse again on 11/16 so that is even more reason to keep an eye on that wound. I wasn't aware of (V12's) physician order for the calf high heel protectors so that is why R259 has not had them on. If the previous dressing was that difficult to remove, I am sure it had been on for more than one shift. That dressing was most likely put on by V12 on V12's 12/6/22 rounds. That would make the most sense since V12 saw R259 and treated R259's Left Medial Foot wound that day. V2 (DON) stated R259 should have heels floated, calf high heel protectors in place and have a low air loss mattress. V2 stated Anyone with a Stage 4 pressure ulcer should automatically be on a low air loss mattress. (R259) is on a pressure reducing mattress, but they are not the same. (R259) needs the low air loss mattress. I don't know how we missed that. On 12/9/22 at 9:30 AM, V13 (Regional Clinical Nurse) confirmed the facility did not enter V12's (Wound Physician) treatment orders for R259's Left Medial Foot wound. V13 stated There are no orders entered into the Electronic Medical Record (EMR) for R259's Left Medial Foot pressure ulcer from 12/2/22 through 12/9/22. The staff should have entered those orders into the EMR. I do not know why the orders did not get entered but we (facility) will get it taken care of today. On 12/9/22 at 10:35 AM, R259 stated, They (staff) just dragged those things (heel protectors) in here this morning. I have not had them since I have been here. I want to go home but first I have to get these sores healed up. I will do what the doctor says so that I can get home. R259 confirmed R259 had not been offered or given any style of heel protectors, or air mattress since admission. The facility policy titled 'Prevention of Pressure Injuries' revised 1/10/22, documents the following: Provide a low air loss or other similar surface to those residents who are at high risk according to the Skin Risk Assessment. Low air loss systems will be inflated based on resident's weight, tolerance and functional status with that inflation rate marked on the control unit and checked each shift for correct settings. Residents on low air loss mattresses require the assistance of two staff for repositioning, turning, perineal care, bathing, transfer or other process where the resident may need support. Complete a skin inspection assessment in EMR approximately weekly for the duration of the resident's stay. The undated facility policy titled 'Dressings, Dry/Clean' documents the following: Preparation: Verify that there is a physician's order for this procedure. Label tape or dressing with date, time and initials. The facility's undated Dressings, Dry/Clean Policy, documents the purpose is to provide for the application of dry, clean dressings. This policy also documents to verify a physician's order for the dressing, check the treatment record, clean the wound, apply the dressing. 35380 2.) R29's Physician Order Sheet (POS), dated 11/2022, documents R29's diagnoses as: Morbid (Severe) Obesity due to excess calories, Excoriation (skin picking) Disorder, and Paresthesia of Skin. R29's Care Plan dated 12/7/22, documents potential for pressure ulcer development related to history of pressure ulcer, impaired mobility, and morbid obesity. R29's Minimum Data Set (MDS) dated [DATE], documents R29 is cognitively intact. R29's Skin & Wound Evaluation V5.0 dated 10/20/22, documents a venous skin issue on the left medial malleolus. R29's Wound Evaluation & Management Summary dated 11/16/22, documents stage 4 pressure wound of the left lateral ankle, dressing treatment plan, Alginate calcium, apply three times per week for 22 days, foam dressing apply three times per week for 22 days, peri wound skin prep apply three times a week for 22 days. R29's Medication Administration Record (MAR) and Treatment Administration Record (TAR) both dated November 2022, have no documented treatment order for R29's left lateral ankle wound since 11/18/22. R29's Progress Notes dated 11/29/22, documents R29 was taken to the emergency room . On 12/7/22 at 1:54 PM, V17 (Nurse Practitioner/NP) stated R29 came to the emergency roiagnom on [DATE] and had a dressing on R29's ankle with the date written on the dressing as 11/18/22. On 12/9/22 at 12:31 PM, V1 (Administrator) stated there are no orders documented for treatments for R29's ankle after 11/18/22. On 12/9/22 at 2:48 PM, V15 (Nurse Practitioner/NP) stated the dressing for R29's ankle should have been changed three times a week according to the wound doctor's orders, and there are no orders for R29's dressing changes since 11/18/22. V15 stated there is no excuse for these bandages not being changed. 3.) R56's undated Face Sheet, documents R56's diagnoses as: Chronic Kidney Disease, Peripheral Vascular Disease (PVD), Kidney Transplant Status, Infection of Amputation Stump right lower extremity, Acquired Absence of Right Leg Below the Knee, and Absence of Left Leg Below the Knee. R56's Care Plan dated 12/5/22, has no documentation of pressure areas on the stump of the right leg. R56's MDS dated [DATE], documents R56 is moderately impaired cognition, has medically complex conditions including Coronary Artery Disease (CAD), Heart Failure, Renal Insufficiency, Rhabdomyolysis, Occlusion and Stenosis of Left Carotid Artery. This same MDS documents R56 requires extensive assistance for bed mobility, dressing, and toilet use. Also, the MDS documents R56 has functional limitation in range of motion due to lower extremity impairment on both sides and uses a wheelchair and limb prosthesis. R56's Progress Notes, dated 11/21/22, document R56 returning to the facility with right area on right stump. R56's November 2022 POS has no orders for treatment for R56's right stump area, and there is no treatment documented for R56's right stump on the November 2022 Treatment Administration Record. The Hospital Note dated 11/27/22 documents R56 was admitted to the hospital on 12/27/22. The Hospital Note dated 11/28/22 documents R56 has a pressure sore to the right residual limb measuring eight centimeters by six centimeters with sanguineous drainage. R56's Discharge Summary, dated 12/1/22, documents a primary discharge diagnosis as Infected Right Stump with Osteomyelitis. This same summary documents findings as changes of below the knee amputation, edema and bone marrow edema enhancement of the distal most tibia and fibula consistent with osteomyelitis, overlying soft tissue edema and enhancement consistent with cellulitis. The summary documents there is skin ulceration. On 12/9/22 at 2:03 PM, V2 (Director of Nursing/DON) stated we don't have documents or orders for R56's stump treatment only orders from 12/1/22, when R56 returned from the hospital.

Based on record review and interview the facility failed to monitor a resident who knowingly slid down in bed resulting in a fall with major injury for one (R45) resident in a sample list of 65 residents. This failure resulted in R45 sustaining a fracture of the right femur. Findings include: R45's undated Face Sheet documents R45 admitted to facility on 8/5/21 with diagnoses including Acute and Subacute [CONDITION(S)], Recent History of Urinary Tract Infection, Right Upper Arm Muscle Contracture, Stage 4 Pressure Ulcer Left Buttock, Sacral Pressure Ulcer, [CONDITION(S)], [CONDITION(S)], and Acute and Chronic Respiratory Failure. R45's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 7 out of 15 total possible points indicating moderate cognitive impairment. This same MDS documented R45 as requiring extensive assistance of two staff for bed mobility and transfers. R45's Care Plan intervention dated 8/21/21 documents for staff to use two staff for bed mobility. R45's Physician Order Sheet (POS) dated September 1-30, 2021 documents a Physician order for a low air loss mattress for wound management ordered 8/20/21. R45's Nurse Progress Notes documented on 9/6/21 at: 6:00 AM V18 (Licensed Practical Nurse/LPN) documented At 0600 CNA was doing walking rounds and observed res. on floor beside low bed. 9:30 AM V19 (LPN) documented Night nurse (V18) spoke with resident's daughter (V24), she (V18) stated she (V24) would like her mother (R45) sent in to be looked at to rule out any issues with her (R45) considering she (R45) is saying she (R45) is in pain. Mobile X-ray has been notified and will be out today. Resident (R45) has been in her (R45) room this morning screaming out 'help me, help.' When staff arrived in her (R45) room she (R45) stated she (R45) wanted a drink of water and her (R45) leg was broken. (V19) Told resident (R45) that there was a call out for portable X-ray. Resident's (R45) legs were assessed for injury; no obvious issues and resident (R45) had full range of motion (ROM). Resident (R45) was asked to use call light to notify staff of issues, not to holler out causing alarm when it is not an emergency. 9:06 PM V19 (LPN) documented Mobile X-ray came around 6-630 pm performed X-ray. Received call from radiologist stating that resident (R45) has a fracture to the right distal femur. Family notified, Physician (V25) called for further orders. Physician (V25) wanted patient (R45) sent out (to emergency room ). Resident (R45) sent to hospital to evaluate and treat. R45's Post Fall Report dated 9/6/21 at 6:57 AM documents resident description: When resident (R45) was asked what happened resident (R45) stated 'I don't know. I was sliding.' R45's Computerized Tomography (CT) report dated 9/6/21 documents findings: there is a commuted impacted fracture of the distal femoral metadiaphysis with lateral angulation and displacement of the main distal fracture fragment. The fracture extends to the anterior superior knee joint space. There is a joint effusion. impression: distal femur fracture. On 9/10/21 at 11:05 AM V2 (Director of Nurses/DON) stated She (R45) was constantly sliding down in the bed due to she (R45) was on an air mattress. V2 stated staff were continually repositioning her (R45) back to center of bed. V2 stated It was our (facility) oversight for not monitoring her (R45) more closely and not adding this safety need to her (R45) care plan. On 9/10/21 at 11:30 AM V25 (Physician stated) V25 was not notified of (R45's) fall until after portable X-Ray results were reported to V25. V25 stated There was a new nurse at facility that day and I told her (V19) that the Physician always has to be made aware of any fall. V25 stated I (V25) would have sent this patient (R45) out to the emergency room . She (R45) is paraplegic and blind and complaining of pain after a fall. Mobile X-Rays are not always accurate. She (R45) should have been sent to the emergency room for evaluation and X-Rays. I (R45) was never notified that the family wanted her (R45) sent into the emergency room . I would rather have her gone to the emergency room rather than obtain a portable X-Ray. The facility should have called me, but they (facility) did not. The facility should have been monitoring her (R45) more closely in order to prevent such a fall with such a major injury. This fall and surgery could have been prevented. On 9/10/21 at 12:00 PM V18 (LPN) stated (V18) was on duty the early morning of 9/6/21. V18 stated Staff had checked on her (R45) several times during the night due to she (R45) kept sliding down in bed because of the air mattress. She (R45) would wiggle enough to get to a more dangerous position and staff would reposition her (R45). On 9/10/21 at 2:00 PM V1 (Administrator) stated R45 was known to put both feet over side of bed. V1 stated We (facility) should have managed that better. We (facility) should have care planned for this. Maybe if everyone (staff) would have known to monitor her (R45) more closely, this might not have happened. She (R45) fell and broke her (R45) femur. That's our (facility) fault.

Based on interview and record review, the facility failed to identify a change in condition, failed to provide oversight of self-care to the feet, and failed to assess and notify the physician of refusal of care for R4. These cumulative failures resulted in avoidable wound deterioration leading to tissue necrosis of R4's right foot. R4 is one resident (R4) of six residents reviewed for wounds in the sample list of six. Findings include: R4's undated Face Sheet documents the following [DIAGNOSES REDACTED]. R4's Minimum (MDS) data set [DATE], documents [DIAGNOSES REDACTED]. R4's hospital discharge Skin Assessment sheet dated 11/1/2017, documents a [MEDICAL CONDITION]. The facility's Preventative Skin Care Policy dated 9/15/19, documents it is the responsibility of the Charge Nurse and the Nursing Assistant to ensure that preventative skin care is completed. The facility's Foot Assessment Policy dated 9/15/19, documents all residents with Diabetes will have a Foot Assessment completed upon admission and quarterly and it is the responsibility of the Charge Nurse to ensure that an assessment is completed on each resident as indicated and if issues are identified appropriate treatment/follow-up will be initiated. R4's Initial Wound Evaluation and Management Summary dated 12/31/2019, documents diabetic wound of the right, plantar foot for at least 1-day duration. R4's Wound Evaluation and Management Summaries dated 12/31/2019, documents diabetic wound of right plantar foot and 1/7/2020 (same area), 1/14/2020 diabetic wound of the right foot, 1/21/2020 diabetic wound of the right heel, 1/28/2020 diabetic wound of the right foot, 2/11/2020 diabetic wound of the right, plantar foot, 2/18/2020 diabetic wound of the right, plantar foot. R4's Skin Inspection Assessments dated throughout January 2021, February 2021, March 2021, do not document any right foot issues for R4. V6 (Licensed Practical Nurse/LPN) completed Skin Inspection Assessments for R4 on 2/1/21 and 2/15/21, both documenting R4's skin as clear with no mention of R4's right foot/ankle. R4's Care Plan dated 3/5/2021, documents for focus area Diabetes Mellitus, to check all of body for breaks in skin and treat promptly as ordered by doctor and refer to podiatrist/foot care nurse to monitor/document foot care needs; (initiated 11/1/2017); for focus area Self-care Deficit, shower/bed bath at least two times a week and as needed (initiated 1/23/2020); for focus area Potential for impaired skin integrity, to observe skin integrity during AM/PM care, notify doctor promptly of skin breakdown, bath/shower per schedule, evaluate skin weekly (all initiated 11/1/2017). R4's bath sheets dated 2/4, 2/9, 2/16, 2/18/21, document R4 refused. R4's bath sheets dated 2/11, 2/23, 2/25/21, document refused, gives self-partial bed bath. R4's Physician order [REDACTED]. R4's Treatment Administration Record (TAR) dated December 2020, document this treatment as completed on all days/evenings in December except 12/14/20 (days); January 2021, all days/evenings as completed; February 2021, all days/evenings completed except 2/4/21 (evening); and March 2021, all days/evenings completed from the first through the fifth of the month. There is no order in R4's medical record that states R4 may self-apply moisturizer to R4's bilateral lower extremities. R4's nursing notes dated 1/12/21 through 3/7/21, do not document the doctor being notified of refusals for care. On 3/9/21 at 12:19 PM V2 (Director of Nursing/DON) stated when the nurses are charting body skin assessments as completed then the whole body should be viewed/assessed. V2 stated the nurses should have been documenting R4's treatment refusals and should have let the doctor know R4 was refusing treatment. V2 stated, R4 never saw the doctor for that foot (right) and when we finally saw R4's foot, R4 was sent out. We smelled an odor in R4's room last week. When we talked to R4 on Friday, R4 stated R4 got band aids from R4's brother and was dressing R4's foot himself. V2 stated the nurses should have been documenting R4's treatment refusals and should have let the doctor know R4 was refusing treatment. On 3/10/21 at 11:24 AM and 12:14 PM, V5 (LPN) stated V5 did not check R4's feet because R4 was going out to smoke. V5 stated. For a skin inspection we are supposed to look at everything but R4 wouldn't let me (V5) look at R4's feet. R4 is coherent and when I (V5) asked R4 if we should look at anything else, R4 said 'no.' V5 stated V5 did check R4's hands and gave R4 insulin so technically R4 didn't refuse all care. V5 stated V5 is aware R4 is diabetic, R4 gets insulin. V5 stated, If someone is diabetic, we should focus on joints areas, heels, coccyx, anywhere that sores can form. V5 stated V5 should have reported refusals to the doctor. V5 stated, In the Treatment Administration Record (TAR), the lotion for R4 is PRN (as needed) and I (V5) always encourage R4 to do it so I (V5) trust him (R4). R4's Skin Inspection Assessments dated 1/11/21 and 1/18/21, completed by V5, both document R4's skin as clear with no mention of R4's right foot/ankle. On 3/10/21 at 1:09 PM V7 (LPN) stated, If a resident refuses care, we should notify the doctor. I (V7) did not notify the doctor and I (V7) don't have a reason why I didn't. Refusals (of care) should be documented in the nursing notes. R4 wouldn't let me (V7) put lotion on R4's feet only from the top of his ankle socks to bottom of knees. V7 stated V7 did not document R4's refusal of moisturizer and V7 did not let anyone know about it. V7 stated V7 is aware R4 is diabetic and V7 knows what to look at, they (diabetics) are prone to getting sores on their feet. R4's Skin Inspection assessment dated [DATE], completed by V7, document R4's skin as clear with no mention of R4's right foot/ankle. R4's Wound Care Progress Notes - Final Report - from the hospital dated 3/6/2021, documents: skin - multiple areas of necrosis to the right foot including the entire fifth toe and lateral aspect of the foot, the plantar aspect of the foot near the area of the first metatarsal head, the medial aspect of the first metatarsal head and great toe, and just proximal to the anterior/lateral/posterior ankle. The foot is malodorous. There is no active exudate, however, several of the necrotic areas are very boggy; Peripheral vascular - bilateral lower extremities warm to cool from knees to toes, skin dry and flaking, sparse to no hair growth, toenails are thickened and yellow, distal aspect of right foot is dusky with delayed capillary refill, right dorsalis pedis pulse not palpable or audible with handheld Doppler (ultrasound), right posterior tibial pulse is not palpable, but is audible with Doppler; assessment/plan - patient has extensive necrosis to the right foot and signs of Peripheral Artery Disease, recommend computerized tomography (CT) to lower extremities to further assess arterial blood flow status to guide decision making regarding debridement/amputation, concerned foot may not be salvageable at this point. On 3/10/21 at 10:24 AM V3 (Medical Doctor) stated, R4 is diabetic and a smoker and R4 has had issues with both feet from diabetes. The nurses did not inform me (V3) they were not putting moisturizer on R4's feet. The nurse should have notified me (V3) if R4 was refusing lotion to his feet. V3 stated if the nurses were applying the lotion twice a day, they should have seen R4's feet and what was going on with them. Feet should be assessed when someone has diabetes and if the nurses had been doing the lotion all along, I (V3) don't think R4's foot would have gotten so bad because they could have called me (V3) sooner and R4 could have gotten treatment.

Based on observation, interview, and record review the facility failed to investigate the root cause and implement behavioral interventions to prevent recurrent injurious behaviors for two of three residents (R1, R3) reviewed for accidents on the sample list of 13. This failure resulted in R3 having multiple hip dislocations requiring emergency room visits to place hip back into correct position. Findings include: The facility's Accident and Incident policy dated 9/15/19 documents under 4. Investigate and Follow/up Action that, The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. 1. R3's admission notes dated 8/21/20 document R3 was admitted to the facility on [DATE] at 4:03 PM. This note documents R3 had a hip replacement on 8/2/20 after having a fall prior to admission into the facility. This note documents R3 will have an abduction brace to the right hip. R3's care plan dated 8/26/20 documents R3 has a [DIAGNOSES REDACTED]. R3's nursing notes dated 8/27/20 at 3:43 PM documents R3's brace was on the floor. This note documents R3 will be sent back to the hospital for hip. R3's nursing notes dated 8/28/20 at 12:47 AM documents at 4:00 PM on 8/27/20, R3 kept taking brace off and throwing it on the floor which caused hip to pop out again. R3 sent to emergency room to have hip put back in socket. R3's nursing notes dated 8/29/20 at 6:53 PM documents R3 removed brace three times since 3:00 PM. R3's nursing notes dated 9/4/20 at 2:17 PM documents R3 had a surgical revision to the hip on 9/1/20 and that R3 is to wear hip brace at all time. R3's nursing notes dated 9/11/20 at 1:15 PM, document noted internal rotation of right hip. This note states staff reports that R3 has been pulling on the straps to both the brace and the pillow. This note documents R3 has had a history of [REDACTED]. devices (abduction brace). R3's nursing note dated 9/11/20 at 1:21 PM, documents R3 was sent to the emergency room . R3's nursing note dated 9/11/20 at 8:45 PM documents R3 returned from the emergency room and that R3's hip was dislocated and put back into place. R3's nursing note dated 9/12/20 at 3:17 PM documents R3 removed brace and abductor and right leg is rotated inward. R3 sent to the emergency room for evaluation. R3's nursing note dated 9/13/20 at 1:05 AM documents no abductor sent back from the emergency room with R3 due to abductor brace broken. R3's nursing note dated 9/13/20 at 9:47 AM, documents R3's right hip has a bulge and right knee is facing inward and that a stat (immediate) X-ray was ordered. R3's nursing note dated 9/13/20 at 11:09 PM documents R3 returned from emergency room with an abduction pillow and that hip was put back in place in the emergency room . R3's nursing note dated 9/16/20 at 2:14 PM documents R3 was sent to the emergency room due to hip dislocation. R3's nursing note dated 9/27/20 at 10:36 AM, documents R3 was sent to the emergency room for a dislocated hip. On 10/01/20 at 10:13 AM, V2 (Director of Nursing) stated R3 fought the brace since the day R3 got to the facility. R3 was constantly noncompliant due to cognitive status. R3 was constantly removing the brace and abductor pillow. V2 stated all emergency room visits were due to R3 removing brace or messing with the brace and causing displacement of the right hip. V2 stated the facility would basically redirect R3 from removing brace. V2 stated there are not interventions in place for R3's behaviors of removing brace in R3's plan of care. 2. R1's wound assessment dated [DATE] documents two skin tears to the upper arm and bruising around elbow. R1's injury of unknown source form dated 9/13/20 documents: resident locomotes in w/c (wheelchair without) regard to surroundings. This form documents that protective skin sleeves will be implemented to prevent further injury. R1's care plan documents a focus dated 1/02/20 that R1 roams hallways with no regard to surroundings. All interventions on this care plan are dated 1/2/20 which include reminders to open eyes, redirect, and remind R1 where R1 is going. R1's care plan dated 1/02/20 does not document protective skin sleeves as an intervention. On 9/30/20 at 10:09 AM, V24 (Licensed Practical Nurse/LPN) stated on 9/12/20 at 8:51 PM that, (R1) had a skin tears to the right and left upper forearms near the elbows. I don't know how (R1) got them but (R1) is prone to skin tears. We (the facility) already had protective skin sleeves implemented but (R1) doesn't leave them on well. (R1) was not wearing long sleeves or (skin protective sleeves) when I assessed (R1). The skin tears did look new. I cannot remember who was working that night and told me about (R1's) skin tears, but we found the skin tears when they put (R1) to bed. I did not investigate the root cause or put in an immediate intervention into place. No one has called me to interview me about how (R1) obtained the skin tears. (R1) is a wanderer and will propel self in wheelchair with head down and will run into things and get skin tears.

Based on observation, interview and record review the facility failed to ensure that two (R1, R4) residents were free from sexual abuse, perpetrated by residents (R2, R5). R1 and R4 are two of four residents reviewed for resident to resident sexual abuse in a sample list of 15 residents. This failure caused R4 to experience physical trauma (vaginal bleeding) and psychosocial trauma including tearfulness and fear following the incident with R5. The facility failed to ensure R4 was not subjected to sexual assault by another resident, R5. This failure resulted in Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remained out of compliance at a Severity Level 2. The facility is in the process of implementing re-education components and training related to abuse policies and procedures. This failure also caused another resident, R1 to experience psychosocial trauma including feeling violated, embarrassed, and angry following the incident with R2. Findings include: 1. R4's Order Summary Report printed [DATE] includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively impaired. R4's Summary of Investigative Findings dated [DATE] states At approximately 1:15 PM V1 Administrator was notified by the nurse (V3), Licensed Practical Nurse (LPN) of an allegation of resident to resident abuse between R4 and R5. There is no documentation by V3 in the progress notes. R5's Order Summary Report printed [DATE] includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Minimum Data Set (MDS) documents R5 as moderately cognitively impaired. R5's Care Plan documents R5 has impaired cognitive function/dementia or impaired thought processes r/t (related to) Difficulty making decisions, Alcohol Dependence with Withdrawal [CONDITION(S)] so R5 tends to forget things. There is no mention of sexually inappropriate behaviors in R5's Care Plan or other documentation. There is no documentation in R4 or R5's medical record that there has ever been a history of consensual sexual or physical relations between R4 and R5. On [DATE] at 1:00 PM V3 (Licensed Practical Nurse/LPN) stated On [DATE] at around 1:00 PM R4 was walking down the hall crying and looked really upset. I approached R4 and asked her what the matter was. R4 stated 'R5 came in my room and put his whole fist in my vagina. I didn't want him to and now I went to the bathroom and I'm bleeding down there.' R4 has mild dementia, but she very well knew what was going on. I immediately called V1 (Administrator). V1 came in and called the police and the family, and we sent R4 to the hospital. I made a written statement to V1 and V1 took care of the documentation since V1 is the abuse coordinator. On [DATE] at 11:00 AM V1 stated R4 reported to (V3) on [DATE] R4 had some vaginal bleeding after R5 put four fingers in R4's vagina. R4 stated that she didn't want R5 to touch her but R5 did. I believe R4 because R5 had dried blood on R5's knuckles and cuticles. The police were called and at first R5 stated it was consensual but then admitted R5 had touched R4's vagina with R5's fingers. R5 was arrested and is still in the county jail. R4 went home with a care giver after being at the hospital for a rape kit to be done. R5 stated the contact had occurred sometime after dinner [DATE]. V1 denied there was ever any other sexually inappropriate behavior observed from R5 prior to this incident. V1 stated R5 was helpful to other residents and even pushed other residents in wheelchairs sometimes. We had no reason to believe R5 would have done this. R4 and R4's family are the nicest people. R4's husband was even here for a while. R4 was content and visited with staff and other residents. There had not been anything between R4 and R5 until this. On [DATE] at 1:47 PM V11 (Power of Attorney for R4) stated R4 is at home with family and a care giver now. R4 was crying at the hospital. R4 talked about what happened for a while but hasn't for a few days. I believe R4's dementia worsened after R4 went through the abuse and had to have the rape kit at the hospital. R4 was very upset at the hospital and when R4 was questioned by the police. R4 cried on and off for a while. I think it would happen again if it is brought up to R4. It has also been hard for R4 to get used to being at home. The routine at (the facility) was good for R4 and it took R4 a while to get used to a new routine. R4 is married and (R4's husband) is still living. R4 would never have done anything like what happened if it were up to R4. R4 was a happy person. R4 has had depression for years, but R4 knows when R4 is sad and asks for something to do like help around the house and when R4 is occupied it take R4's mind off the sadness. On [DATE] at 9:58 AM V14 (Rape Crisis Counselor contracted by local hospital) stated I was called into the emergency room ([DATE]) when the rape kit was being done on R4. R4 is in the early stages of dementia so some details like exact time it happened were not clear, but what was consistent with every person who interviewed R4 was a male she knew inserted fingers into R4's vagina and then R4 had some vaginal bleeding. I do believe R4 knew what happened and I believe R4. Sometimes the trauma of a situation like that can get confused even in a person without dementia. R4 was tearful at times and very upset and frightened. On [DATE] at 11:00 AM V13 (Registered Nurse/RN) who is the emergency room nurse who assisted R4 on [DATE] (when the rape kit was done) stated R4 did cry at times when R4 talked about what happened. R4 was consistent in the statement that R5 had inserted R5's hand into R4's vagina and that R4 had bleeding from her vagina. The rape kit is traumatic too. I am convinced that something happened to R4 and it did emotionally upset her. On [DATE] at 9:03 AM V22 (a detective who works with sexual assault cases for the police department) stated I am reading the report from [DATE]. R5 had blood around R5's cuticles on one hand. We took samples. R4 had blood on her clothing that was sent to the state police lab. At first R5 stated it was consensual and R5 did not penetrate R4. But when R5 was asked about the blood on R5's fingers, R5 admitted that R5 had inserted R5's index and middle fingers into R4's vagina and R4 was bleeding. R5 stated this had happened sometime the evening of [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when R5 sexually assaulted R4. On [DATE] at 9:10AM V1 was notified of the Immediate Jeopardy situation. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: a. On [DATE] at 9:10AM V3 verified that R4 was assessed by V3, after R4 notified V3 of the assault ([DATE]). R5 was placed on 1:1 monitoring by V52 (Certified Nurse's Aide/CNA). This was verified by V52 on [DATE] at 9:13AM. On [DATE] at 9:00AM V1 stated V1 initiated an investigation. Police were notified by V1. V11 (R4's Power of Attorney) and V17 (R4's physician) were notified by V1. Staff were interviewed regarding the incident by V1 and V2 (Director of Nursing/DON). On [DATE] at 9:30AM V2 verified that he interviewed staff about the assault on R4 on [DATE]. On [DATE] at 9:00AM V1 stated R4 was sent to the hospital for evaluation. R5 was apprehended by the police. On [DATE] V1 provided documentation that the assault was investigated and reported to the state agency [DATE]. b.) Alert, oriented residents were questioned by V1, V2, V21 (Quality Assurance Nurse), and V10 (Activity Director) regarding any complaints of abuse or inappropriate sexual touching on [DATE]. Female residents with cognitive deficits were asked to be physically examined for any signs and symptoms of physical abuse by V21 and V2 on [DATE]. Residents were screened for abuse and neglect potential by V21 and V12 (MDS Coordinator) on [DATE]. Documentation of these interviews and assessments was provided [DATE]. On [DATE] at 10:32AM V2, V21, and V10 verified they had completed this documentation. c.) Staff were re-educated regarding the abuse and neglect policy on [DATE] by V2 and V1 and again on [DATE] by V53 (Clinical Consultant). V1 was re-educated by V53 regarding the abuse and neglect policy and reporting and investigating abuse on [DATE]. All staff will be reeducated at least every three months and PRN regarding the abuse and neglect policy by V2. Residents will be screened for a history/potential for abuse upon admission by V12 and/or V21. V1 will complete spot checks at least weekly for compliance going forward. Current residents will be screened quarterly for potential abuse/harm and care planned for the potential of abuse by V12. V1 will complete spot checks at least weekly for compliance going forward. Documentation and sign in sheets were provided by the administrator on [DATE] to support that the staff education was initiated [DATE] and a written plan is also documented to continue this process. On [DATE] at 10:15AM V2, V12 and V21 voiced that they had started education on [DATE] and are aware of the plan to provide training concerning abuse and neglect at least every three months and any time there is any suspicion of or actual abuse. d.) Per interview with V1 on [DATE] at 11:07 AM, V1 will interview five residents weekly for 16 weeks and randomly thereafter, to monitor for concerns regarding abuse or being touched in a sexual manner. These interviews commenced [DATE]. Findings will be reviewed at the Quality Assurance meeting monthly. Interventions and a strategic plan will be developed, implemented, and remain in place until resolution. V53 will monitor on a monthly basis to ensure compliance in regard to abuse and neglect allegations. V1 provided documentation to support that this process has been initiated. V1 stated We are committed to follow this plan. On [DATE] from 9:00AM to 1:00PM and again on [DATE] from 9:00AM until 12:00PM observations were made on all three halls of the facility. Staff were observed interacting with and supervising residents. No residents were observed to exhibit any behavior that would indicate fearfulness or anxiety. Direct Care staffing for [DATE] was reviewed. The facility met or exceed the accepted resident to staff ratio taking into consideration the care needs of the residents residing at the facility. 2. R1's Order Summary Report printed [DATE] includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. R1's Care Plan dated [DATE] states This resident has the potential for abuse/neglect due to Depression diagnosis, Inappropriate behaviors affecting others - such as provoking, disrespectful actions or comments, attention seeking outburst, Invading other's space and property, Rummaging through belongings or wandering in and out of other's spaces, Physical vulnerability such as poor ambulation or inability to ambulate/propel wheelchair, frailty/weakness, Underlying factors that increase vulnerability, including dementia, confusion, poor judgment, wandering and giving away personal property. R2's Order Summary Report printed [DATE] includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] R2's Care Plan updated [DATE] documents Resident is sexually inappropriate and masturbating in public areas r/t (related to) Dementia. Staff reports that patient was noted standing over his roommate masturbating, patient does not recall event. Resident will also yell from his room stating that he needs his (slang for penis) sucked. Resident does not recall saying any of it. R2's care plan history from [DATE] until [DATE] documents R2's public masturbation was first identified [DATE] standing over R2's roommate masturbating was added to the care plan on [DATE]. A Care Plan problem statement related to R2 documents, yell from R2's room R2 'needs his d*** (penis) sucked' was added [DATE]. From [DATE] until [DATE] during this escalation of R2's sexually inappropriate behavior the only interventions documented were to take R2 to his room if seen masturbating in a public area and make sure the door is shut if R2 is in room. There was no documentation of how other residents were to be protected from R2's behavior. On [DATE] at 2:48PM V12 (Care Plan Coordinator) verbalized in looking back on the care plan history, the facility has been aware of R2's disrobing and masturbating in common areas of the facility since 2016. On [DATE] at 1:15PM V12 stated As far as I know the only interventions we have had are to take R2 back to his room and make sure the door is shut. R2's medical record documents the following aberrant sexual behaviors: R2's SBAR (Situation, Background, Assessment, Recommendation) report dated [DATE] documents R2 was seen standing over roommate, while roommate was in bed, masturbating. The Licensed Practical Nurse who signed this report is no longer employed by the facility and is not available for interview. On [DATE] V1 verbalized the roommate referred to has since died . V38's (Psychiatrist) evaluation dated [DATE] documents R2 was seen at the nursing home [DATE] due to frequent self-masturbation. Unfortunately R2 does this in the hallway in front of staff and other patients. Attempt to redirect to his room frequently is not successful. R2 also walks around in the hallway naked. When attempted to redirect patient states 'I can walk around naked anytime I want to.' There is no documentation included in R2's medical record of psychiatric follow-up after this evaluation. Record review documents the following: On [DATE] V40 (LPN) documented in a progress note R2 told a Certified Nurse's Aide to suck my (penis). On [DATE] V40 documented R2 was sitting in the hall masturbating. Social Service Assessments dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] all include notes describing R2's frequent masturbation in common areas of the facility with other residents present and sexual remarks to staff. On [DATE] at 1:11PM V4 (LPN) stated that on [DATE] R1 said you gotta get me out of this room. R2's a q*** (derogatory). R2 tried to j*** (sexual reference) me off and I had to push him off me. It was a Sunday. I know I talked on the phone with V1 about this. On [DATE] at 2:10PM V43 (Certified Nurse's Aide/CNA) stated R2 plays with himself all the time. They have moved a couple roommates out because of that. I can't remember who. On ([DATE]) R1 put his light on. I went into the room and R1 said 'Get me the f*** (expletive) out of this room.' I asked why and R1 told me R2 had asked R1 to suck his d*** (penis). R1 said that R2 had touched his penis. V43 verbalized that she was sure she had called V1 and told V1 about this incident. On [DATE] at 3:35PM V40 (LPN) stated R2 makes sexual comments and frequently masturbates where other residents see it, like in the hall or the dining room. Basically, R2 wants to do whatever he wants and doesn't want to be messed with. We try to redirect him when we see it. On [DATE] at 1:45PM V44 (CNA) stated R2 touches himself a lot. I've seen him do it in the dining room with other residents there. I have heard R2 tell R1 to suck his d***(penis). Last night ([DATE]) R2 went into the hall naked. If R2 is dressed he will put his hands in his pants and masturbate. He doesn't care who sees. On [DATE] at 1:50PM V45 (CNA) stated I work down East hall (where R2's room is) most of the time. R2 cusses a lot and he likes to be naked. A couple of months ago I saw R2 masturbating in the dining room with other residents there. I took him back to his room. On [DATE] R15 (a resident identified by V1 as interviewable) stated I've been here about nine months. There is a guy who just sits in the dining room or wherever else he happens to be and plays with himself. I don't want to see that, so I eat in my room and now we mostly do anyway. When asked exactly R15 meant by plays with himself R15 verified R2 masturbates. On [DATE] at 12:45PM V21 (LPN) verbalized that she was aware of R2's frequent masturbation in common areas. R2's masturbated in the halls and the dining room with other residents. I am aware that R2 has stood over another resident and masturbated. R1 is truthful and knows what goes on. I would believe R1. On [DATE] at 3:33PM V4 (LPN) stated ([DATE]) I went in R1's room to give medications and R1 said 'I need to get out of this room. My roommate R2 (masturbated) me. I'm not a (derogatory term for homosexual male) and I didn't want it and I don't want to be around R2.' I immediately called V1. I don't think I documented anything because V1 is the abuse coordinator and V1 took over from there. When asked if it was V4's impression that R1 was telling her R1 was touched against R1's will by R2, V4 stated Definitely, I have known R1 since I was a kid and I think R1 was angry and wanted out of that room. R1 said it happened that day ([DATE]). R1's Grievance/Complaint Resolution Report dated [DATE] documents R1 reported to nurse R1 wanted out of room because R2 was a (derogatory term for homosexual male) and R2 asked R1 to sexually gratify R2. V1 denied an investigation was done concerning this because I talked to R1 and R1 denied any contact. I did not consider it abuse. V1 identified the nurse referred to on the grievance as V4 (Licensed Practical Nurse/LPN). No documentation of this occurrence is present on R1's or R2's medical record. On [DATE] at 11:00am when asked why R1's request for a roommate change was not addressed V1 stated R1 denied it and I didn't hear anything more about it. R1 was in the room with R2 until [DATE] when he was moved to an isolation room because of a respiratory infection. On [DATE] at 11:55AM R1 was lying in his bed. When asked about the [DATE] incident with R2, R1 stated I remember that. I can't say what date it was, but I told a nurse I trust. I was lying in bed and R2 came over to me; I was wearing a gown. R2 is always yelling about needing (oral sex). R2 plays with his (slang for penis) all the time. It's sick, but I got used to it. R2 came over by my bed in wheelchair and reached under my gown and started to touch me. When asked where R2 touched R1, R1 pointed to R1's groin. R1 stated R2 (derogatory term for masturbation) my penis. When asked how it made him feel, R1 stated I felt violated. I am not a (derogatory term for homosexual male). I have grabbed female staff. I like women. I was too embarrassed to tell too many people. I am not a (derogatory term for homosexual male). When asked if R1 had told V1, R1 stated No just the nurse I trust. At this time, R1 gave permission to have V1 come into room. V1 asked R1 if he had been touched inappropriately; R1 stated Yes. R2 (derogatory term for male masturbation) me off. I didn't want to tell you. I told a nurse I trust. It ([DATE] incident) was when I was over there in the other room before I got sick. When R1 was talking about this ([DATE] incident) R1 cast his eyes down and looked at the wall. R1 nervously twisted the sheet around his fingers. On [DATE] at 1:10PM R1 was in his room eating lunch. R1 stated I didn't tell V1 about it (the incident [DATE]) because V1 was already mad at me for grabbing the girls b***s (breasts). I didn't want V1 to think I am a q**** (derogatory). I was embarrassed and I need to have a room here. I don't have any other place to go. R1 pushed his food around on the plate with his fork and avoided eye contact. R1 then stated I'm glad I'm away from that q**** (derogatory).

A.) Based on observation, record review, and interview, the facility failed to ensure that 4 of 7 designated emergency exits were free of snow and ice, preventing a clear pathway for egress of residents in the event of a fire or need for evacuation. This failure placed all 49 residents at risk. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12-17-13, the facility remains out of compliance at a Severity Level 2, as the facility continues to monitor the effectiveness of staff education. Findings include: A modified tour was conducted at 1:35 P.M. on 12-17-13 to ensure that all seven emergency exits had clear pathways to a public way. The Maintenance Director, E5 was present during the tour. According to the facility floor plan and posted evacuation route, the facility has seven designated emergency exits to be used during emergencies for evacuation: the North (main) entrance, the North (Dining Room) exit, and the North (Service) corridor exit doors, the Northeast exit door from the East resident corridor, the Northwest exit door from the West resident corridor, and the Southeast and Southwest exit doors from the"Core" resident corridor. The three North emergency exits were clear and they open into the parking lot/public way. The four other emergency exits' (Northeast, Northwest, Southeast and Southwest) walkways (sidewalks) were not clear and had 6 inches of snow on them. The four exits paths empty into the parking lot on the north side of the facility and were not clear to permit unobstructed passage away from the building. E5 stated on 12-17-13 at 1:35 P.M. that the area had 6 inches of snow on 12-13-13 and 12-14-13. E3 stated the snow stopped around 12:00 P.M. on 12-14-13. E5 was asked if it would be difficult to wheel and walk residents in the snow. E5 stated that it would. E5 stated that he was not aware that the emergency exit pathways to a public way are to be clear. According to the facility's Centers for Medicare and Medicaid Services, CMS-672 (Resident Census and Condition of Residents) completed 12-17-13, 49 residents reside at the facility. The facility documented that 20 residents use wheelchairs, 25 residents require assistance of staff to ambulate and 4 residents ambulate independently. On 12-19-13 at 2:30 P.M.,The Director of Nurses, E2 stated that she believed that no residents could safely ambulate independently in the snow outside of the emergency exits. The Administrator, E1 stated on 12-17-13 at 1:45 P.M. that she did not realize that the walks were not clear. E1 was asked for a policy for snow removal. E1 did not provide a policy for snow removal or procedures to maintain a clear path to a public way in case of emergencies. E1 did provide a "Daily Room Rounds" checklist or audit tool that was for the maintenance personnel. The "Daily Room Rounds" was designed to be used daily. Number 3 on the list states "Observe sidewalks for any hazards that may cause falls." E1 stated on 12-19-13 at 11:10 A.M. that the snow on the North parking lot was commercially removed and E5 removed the snow from the three North emergency exits on 12-14-13. An Immediate Jeopardy was identified on 12-17-13. E1, Administrator, was notified of the Immediate Jeopardy on 12-17-13 at 3:50 P.M. The Immediate Jeopardy was identified to have begun on 12-14-13 when staff failed to remove snow accumulated and ice from the emergency exit walkways to the public way following the winter snow storm on 12-13-13 and 12-14-13. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. On 12-17-13 at 3:00 P.M. E5 had removed the snow and ice from all emergency exit walkways to a public way. 2. On 12-17-13 at 5:10 P.M. E4, Regional Director of Operations conducted an in-service with E1 and E5. The snow removal in-service discussed the facility's actions to be taken in the event of anticipated snow accumulation and staff responsible. E1 and E5 demonstrated knowledge and competency with information presented to them regarding maintenance of emergency egress pathways. B.) Based on record review and interview facility staff failed to safely transfer a resident (R17) by using a gait belt. This failure resulted in R17 falling to the floor and sustaining a fractured right tibia. R17 is one of seven residents reviewed for falls in a sample of 13. Findings include: The Minimum Data Set (MDS) dated ,[DATE] documents the following information on R17: [DIAGNOSES REDACTED]. R17 is documented as an extensive two person assist for all transfers and toileting. R17 is documented as not able to stabilize herself without the help of staff. R17 is documented as cognitively intact. A facility report titled "Fall Risk Evaluation" documents R17 as a high risk for falls on 12/29/12, 1/6/13 and 1/11/13. A facility report titled "Verification of Incident / Administration Summary" documents that on 1/12/13 at 9:40 pm, R17 was being ambulated by one Certified Nursing Assistant (CNA), E18 from the bathroom without a gait belt. E18 had instructed R17 to turn and back up to the bed and sit down. R17's slippers slipped and R17 was lowered to the floor. E18 left to get assistance from E19, CNA and without an assessment for injuries, lifted R17 to the bed. E18 noted a skin tear and informed E20, Licensed Practical Nurse. E20 then completed a head to toe assessment on R17 per documentation of the report and there were no findings. The same report documents that E18 and E19 were counseled on safety precautions, use of gait belt with transfers, ambulations and fall protocol on falls with nurse assessment prior to moving a resident. A Nursing Note dated 1/13/13 at 7:15 am documents E20, the same Licensed Practical Nurse working the evening before, being called to R17's room by E21 (CNA). E21 had noted swelling and bowing of R17's right lower leg. E20 performed an assessment and then notified Z1, R7's Primary Care Physician. E20 received an order to send R17 to the emergency room . R17 was transported to the Hospital emergency room . The Nursing Note goes on to document that at 1:45 on 1/13/13 the facility was notified that R17 had a right tibia fracture and was being admitted to the Hospital for surgical repair of the fracture. A facility report titled "Verification of Incident / Administration Summary" and dated for 1/13/13 documents that R17 was not toileted during the night of 1/12/13 (per R17's request) after R17's fall, but had been checked on every two hours through the night and no deformity of the right leg was noted by E15, Licensed Practical Nurse. A facility report titled "Gait Belt, Use of" and dated 2008 documents that the policy of the facility is that "staff will help control and balance (by using a gait belt) residents who require assistance with ambulation and transfer." The facility Policy titled "Transfer Activities" and dated 2006 documents the following:" Purpose...To transfer the resident from bed to chair, toilet or tub safely, Equipment.....Transfer Belt, Procedure...Obtain assistance of another individual if necessary for safe transfer, Apply transfer belt." On 12/19/13 at 4:40 pm E2, Director of Nursing stated that it is the facility's policy and E2's expectation that staff use a gait belt when a person has been assessed as high risk for falls and is an assist for transfers and ambulation. "...How else would staff be able to prevent a fall if there was no gait belt used, you can not grab their arms." E2 acknowledged that E18 did not transfer R17 per facility policy and therefore R17's fall may have been preventable. E2 also acknowledged that E18 and E19 should not have moved R17 from the floor to her bed prior to R20 being notified and completing an assessment.

Based on interview and record review the facility after identifying an abdominal wound found on R3, failed to notify the Physician and failed to get an order of treatment. The facility also failed to track and measure the wound after it was identified. The wound deteriorated and R3 required hospitalization and surgery. R3 is one of three residents reviewed for infection control out of a total sample of seventeen. Findings include: The September 2010 physician's orders [REDACTED]. Nurses notes dated: 8/25/2010 "...Res (resident) has dark pink (and) purple bulge RLQ (right lower quadrant) of ABD (abdomen). Res c/o (complaining of) pain when touched. Area is soft, feels like it's fluid filled. Measures 3cm (centimeters) x 6.4 cm. Physician notified. Will monitor..." The note is signed by E9 Licensed Practical Nurse (LPN). Nurses notes document: "...8/26/10 Pink (and ) purple area still present on RLQ Abd. No discharge..." On 8/27/2010 "...pink (and) purple still present. RLQ will continue to monitor..." On 8/28/2010, "...Area to RLQ remains red (and) swollen, tender to touch..." 8/29/2010, "...sore abdomen draining purulent green drainage...", "...8/29/2010 Res admitted to (hospital) POA (Power of Attorney)says there (sic) are keeping overnight for surgery tom (tomorrow)..." E9 LPN stated on 9/8/2010 at 2:00 PM that she called the Physician on 8/25/2010 but could not get through because the phone lines were down. She stated she failed to follow up on the attempt to contact the Physician. A facility form titled "Counseling One on One Inservice Form" reads "...Re education was given to (E9) about notifying MD (Medical Doctor) with any condition change..." The form is signed by E5, Acting Director of Nursing. E5 confirmed on 9/7/2010 at 1:00 PM that she disciplined (E9) for failing to notify the Physician and for failing to follow up. An emergency room report dated August 29,2010 and signed by the emergency room Physician states, "...Over the last week the patient has had a growing abscess on her anterior abdominal wall. Unsure how this started and unsure exactly on length of time that it has been there...We did send her for a CT (computerized tomography) scan that reveals a large abscess that is forming 5 cm or better...We put her on some [MEDICATION NAME] to cover staph. I wrote for 1 gram IV (intravenous) and then pharmacy to dose thereafter...Plans are for (her) to go to surgery tomorrow and have this debrided in surgery..." Assessments of R3's abdominal wound were not present in the medical record. E4, LPN and facility wound care nurse confirmed on 9/8/2010 at 2:30 PM that she did not make out a skin tracking sheet for this wound and that she was not tracking the wound. Z2, Primary Care Physician for R3 stated on 9/8/2010 at 3:00 PM that he was never notified of this wound. He stated that even if the phone lines were down he could have been reached with his beeper. He stated he would have ordered a CT scan and that the outcome for R3 could have been changed and she might not have required surgery. Z2 stated he would have expected the facility to contact him for a problem with one of his patients of that magnitude.